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MEDICAL .SCHOOL
LI ISMAM.1T
Digitized by the Internet Archive
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THE JOURNAL
OF THE
MEDICAL SOCIETY OF
NEW JERSEY
PUBLISHED MONTHLY UNDER THE DIRECTION
OF THE BOARD OF TRUSTEES
Volume XXVIII.
January, 1931— December, 1931
Publication Committee :
Drs. Henry C. Barkhorn, Edward J. Ill, Linn Emerson
J. Bennett Morrison
14 South Day Street, Orange, N. J.
; ; , ’ ; Editor:,*,- » TP/
Henry G. Reik, M.D.v'F.A.C.S,
INDEX
Address, President’s Annual 539
President’s to House of Delegates Aug. Sup. 1
Advertising, False and Misleading Aug. Sup. 8
Aug. Sup. 47
American College of Physicians, Report of Meeting 51.3
American Federation of Hard of Hearing 953
American Medical Association Convention 666
Delegates’ Report of Aug. Sup. 36
American Physiotherapy Association; Letter from Dr.
Harold D. Corbusier 63
Annual Conference, Secretaries and Reporters of County
Societies 956
ANNEAL MEETING—
Assessment of Dues Aug. Sup. 18
House of Delegates Report Aug. Sup. 1-59
Preliminary Program of 435-441
Scientific Sessions, Report of Aug. Sup. 56
Section of Ophthalmology, Otology and Rhinolaryn-
gology , Aug. Sup. 59
Section on Pediatrics Aug. Sup. 61
Section on School Physicians Aug. Sup. 62
Transactions of Aug. Sup. 1-86
Woman’s Auxiliary Aug. Sup. 63-86
Annual Report of Editor and Executive Secretary .Aug. Sup. 6
Asbury Park Convention 579
AUTHORS OF ORIGINAL ARTICLES—
Adams, J. K.: Discussion of Fractures 12
What Is Wrong with the Fracture Situation? 3
Aitken, Frank J. T. : A Group of Endocrine Cases 470
Altschul, F. J. : Fusospirochetal Disease of the Lung.. 834
Arlitz, William J. : Discussion of Fractures 10
Asher, Maurice: Discussion of Duodenal Tube Drainage
of the Biliary System 814
Avidan, Maurice S.: Discussion of Fractures 11
Baker, Charles Frederick: Duodenal Stasis 1
Bancroft, Frederic W. : Thrombosis and Embolism 619
Barbarito, William N. : Discussion of Duodenal Tube
Drainage of the Biliary System 814
Barkhorn, Henry C. : Discussion of Acute Mastoid Dis-
ease 26
Our County, Presidential Address to Essex County
Medical Society 900
Report of Publication Committee Aug. Sup. 2
Beling, C. C. : Report of Judicial Council Aug. Sup. 17
Belk. William P. : Discussion of Fusospirochetal Dis-
ease of the Lung 849
Blanchard, Kenneth: Discussion of Changes in Human
Rickets After Viosterol Therapy 22
Discussion of Clinical Evaluation of a Concentrate of
Vitamins A and D 853
Bland, P. Brooke: Leukorrhea 489
Bowen, D. C. : Health Department Growth in New
Jersey j 196
State Health Laws 59
Bowers, Anna Mae: The Future of Freud 52
Bowles, Harry IT. : Medical Ethics 35
Bradshaw, John Hammond: A Visit to the Royal Vic-
toria Hospital, Montreal 715
C’est Formidable L’ Opinion Publique 717
Hurry, Hurry, Hurry! 952
Lowering of the Standard of Ethics 53
Medical Societies 581
More Health Ethics 143
Patients Must Not Be Neglected 432
Recent Visit to the Grenfell Mission on the Labrador 864
Success 867
The Physicians in Holy Writ 252
Uphold Honor of the Profession 494
“Who Steals My Purse Steals Trash” 359
Bronner, Augusta F. : The Future of Freud 52
Brown. Harvey: Discussion of Pedographic Impressions
in School Children 930
Burton, Opitz R. : Clinical Significance of High and
Low Blood Pressure 302
Caffey, John: Changes in Human Rickets After Vios-
terol Therapy 21
Discussion of Changes in Human Rickets After Vios-
terol Therapy 22
Campbell, William: Advantages of General Anesthesia
in Tonsillectomy < « , « *..., 29
Church, Franklin H.: Forcible Extension in an Anky-
losed Joint ! . i '. .. 9‘l4
Cone, Ralph S.: Requiem to the Unknown Soldier ... 142
The Bell Buoy ^ ^ . 577 1
The War Nurse’s Story 1 ... .^. 14±
Corbusier, Harold D : American Physiotherapy Asso-
ciation , 6^*
Corson, E. S. : Phlebitis 1*2
Corwin, Theodore W. : Discussion of Tonsillectomy 30
Cosgrove, Samuel A.: The General Practitioner and
Obstetrics 545
Coughlan. Ella: Discussion of Pedographic Impressions
in School Children 930
Craster, Charles V.: A Skin Test for Whooping Cough 236
Danzis, Max: Discussion of Biliary Tract Disease _ 797
Discussion of Duodenal Tube Drainage of the Biliary
System 815
Honor to Max Danzis • • 276
Darlington, E. P. : Discussion of Symposium on Public
Health Work 207
Davidson, Harold S. : Diabetes Mellitus and Throm-
bo- angiitis Obliterans in the Same Patient 570
Recurring Postoperative Parotitis 85
Deaver, J. Montgomery: Discussion of Biliary Tract
Disease 299
Deaver, John B.: Surgical Aspects of Biliary Tract
Disease 295
De Meritt, C. L. : Medical Possibilities of Sea Water.. 706
The Acute Abdomen ;• 407
Doane, Joseph C. : What the Present Day Public
Thinks of the Medical Profession 648
Donaldson, Walter F. : A Romance of Paternalism 587
Doody, William: Child Guidance 595
Downs, R. I. : Publicity, a Remedy for Many Society
Problems 959
Dublin George J. : Common Conditions in Industrial
Ophthalmology 704
Dunnington. John Hughes: Clinical Management of
Heterophoria 919
Discussion of Ocular Muscle Abnormalities 927
Eagleton, Wells P. : A Doctor’s Confession of Faith. . 237
Ellis, William J. : Development of Public Welfare Work 187
Ely, Lancelot: Report of Committee on Scientific
Work Aug. Sup. 2
Emerson, Linn: Combined Orthoptic and Operative
Treatment of Convergent Squint in Young Children 923
Discussion of Acute Mastoid Disease 27
Discussion of Ocular Muscle Abnormalities 926-7
Ewing, Harvey M. : Discussion of Cardiac Irregulari-
ties and Silent Mitral Stenosis 912
Fanburg. S. J. : Fungus Infections of the Skin 92
Finkelstein, A. S. : Discussion of Whooping Cough 100
Treatment of Whooping Cough 96
Finkler. Rita S. : The Female Sex Hormone 766
Fish, Clyde M.: New Method of Outlining the Heart,
Its Chambers and Great Vessels 817
Floyd, Rolfe: Treatment of Bright’s Disease 552
Fowler, Robert H. : Discussion of Acute Mastoid Dis-
ease 26
Discussion of Tonsillectomy 31
Tonsillectomy Under Local Anesthesia 27
Gamon. Robert S. : Is Group Medical Publicity Ethical? 961
Gardam, Joseph William: Statistical Study of Diph-
theria in Newark 626
Gerber, Louis J. : Radiographic Diagnosis of Gall-Blad-
der Pathology 829
Gerendasy, J. : Practical Gastro-Enterology 768
Giglio, A. S. V.: Tonsillectomy by Diathermy 77 1
Goldstein, H. H. : Foreign Body in the Urinary Blad-
der 709
Useful Irrigating Fluid for Septic Wounds 492
Goldstein, Hyman I.: Discussion of Cardiac Irregu-
larities and .Silent Mitral Stenosis 913
Hereditary Epistaxis 309
Gowen, Cecil H. : Bacteriologic Study of Chronic In-
fectious Arthritis 38
Gray, John W. : Bacteriologic Study of Chronic Infec-
tious Arthritis 38
Griffin, Guy B.: Liver Cysts 337
Gross, Max: Review of Recent Literature on Thrombo-
angiitis Obliterans 571
Hagertv, John F. : A Case of Pseudo-Hermaphroditism 899
Discussion of Fractures 9
Discussion of Symposium on Public Health Work 208
Memorial Tablet to Dr. O. H. Sproul 110
Haigh, G. W. : Medical Service of the Future 115
Hallinger, E. S. : Sinusitis 475
Hartman. J. C. : Obstetric Mortality 31
^Ifij’twpll, Johiji Continued Education of the
« . I)bc\or . i 639
HeM>\ WillWn : . Tb’e! Jrufure of Freud 52
Heller,' George: ‘ PreVerftton of Measles 617
Heller. N. B . : Alc^ojic^ fse^do- Pellagra 467
Hermnntt/ Jonf\ «H*. : -Liver. \Gy?ts 337
; IJerrn?an, W. 4«G- i $is£fts&it>ij[ of Fusospirochetal Dis-
* ' base of* the *Ltmg •*.•.*... .* 849
INDEX
Fusospirochetal Disease of the Lung 834
Uterine Hemorrhages Radiologically Considered 819
Heyd. Charles Gordon: The Physician’s Economic Con-
tribution to the Community 258
Heyman, Arthur: Discussion of Malnutrition in Chil-
dren 211
Hubbard, H. V. : Discussion of Ocular Muscle Abnor-
malities 926
Discussion of Tonsillectomy 30
Overlapping the Rectus Muscles for Correction of
Strabismus 915
Huberman, John H. : Value of Blood Sedimentation
Test in Gynecology 403
Hull, Donald B. : Discussion of Pedographic Impres-
sions in School Children 930-931
Pedographic Impressions in School Children 928
Hummel, E. G. : Discussion of Whooping Cough 100
Hyman, Albert S. : Myocardosis; the Failing Heart of
Middle Life 831
Treatment of Acute Coronary Thrombosis 296
111, Edward J. : Society for Relief of Widows and Or-
phans of Medical Men of New Jersey 69
Ireland, Allen G. : Discussion of Pedographic Impres-
sions in School Children 930-931
Discussion of the Physician’s Part in the Training
Irvin, John S. : Public Relations as a Specific 959
Jack, H. Wesley: Factors in the Early Diagnosis and ..
Treatment of Fractured Skulls 603
Jaffin, A. E.: Discussion of Cardiac Irregularities and
Silent Mitral Stenosis 912
Discussion of Duodenal Tube Drainage of the Biliary
System 814
James, Bart M. : Common Diseases of the Oral Mucosa 563
Johnson, F. C. : Discussion of Diet in Eczema of In-
fants 223
Discussion of Non-Pathologic Heart Murmurs in
Children 103
Johnson, V. Earl: Modern Treatment of Varicose
Veins 229
Kahrs, Grace M. : The Physician’s Part in the Train-
ing of Teachers 932
Kelley, Charles B. : Discussion of Symposium on Pub-
lic Health Work 206
Kerley, Charles Gilmore: Discussion of Gastro-Intes-
tinal Disorders 20
Gastro-Intestinal Disorders 14
Kessler, Henry H. : Discussion of Fractures 11
State Department of Labor in Relation to the Public
and Medical Profession 200
Kildufle, Robert A.: The Anemia of Pregnancy 341
Kiley, John E. : Occupational Dermatitis 613
Kinch, Frederick A.: Discussion of Pedographic Im-
pressions in School Children 931
Discussion of the Physician's Part in the Training
of Teachers 936
Kipp, Charles J. : Memorial Tribute to Dr. Charles J.
Kipp 275
Klein, Edward C., Jr.: Ruptured Gastric Ulcer 412
Kramer, David W. : Circulatory Disturbances in the
Extremities of Diabetics 560
Krauss, F. I. : Diet in Eczema of Infants 217
Discussion of Eczema in Infancy 228
Discussion of Essentials in Infant Feeding 216
Discussion of Gastro-Intestinal Disorders 20
Discussion of Integration of the Child 109
Discussion of Malnutrition in Children 211
Discussion of Whooping Cough 99
The Practitioner’s View of Medical Economics 743
Kuder, Joseph M. : Local County Medical Society
Publicity %2
Kummel, Max: Medicolegal Aspects of Disability in
Industrial Lead Poisoning 327
Lamson. William J. : Discussion of Pedographic Im-
pressions in School Children 931
Lathrope, George H. : Discussion of Value of Duodenal
Tube Drainage of the Biliary System 813
Etiology, Diagnosis and Treatment of Peptic Ulcer.. 344
Some Difficulties of the Asthma Problem 684
Levy, Julius: Child Hygiene 694
Discussion of Integration of the Child 109
Discussion of Whooping Cough 99
Influence of Public Health Activities on Medical
Practice 193
Lippincott, A. Haines: Presessional Report of the Wel-
fare Committee 438
Regular Report of the Welfare Committee. .Aug. Sup. 27
Littwin, Charles: Discussion of Ocular Muscle Abnor-
malities 926
Lyon, B. B. Vincent: Discussion of Duodenal Tube
Drainage of the Biliary System 815
Value of Duodenal Tube Drainage of the Biliary Sys-
tem in the Treatment oi Disease and Disorders of
the Liver 799
McBride, Andrew F. : Discussion of Fractures 14
Discussion of Symposium on Public Health Work... 206
McCauley, F- J. : Discussion of Eczema in Infancy 228
Eczema in Infancy 223
McGuire, James J. : Annual Report ol Board of Medical
Examiners Aug. Sup. 29
Violations of Medical Practice Act 63
McKiernan, R. L. : Foreign Body in the Urinary Blad-
der 709
McLean, Stafford: Discussion of Changes in Human
Rickets After Viosterol Therapy 21
Maliniak, Jacques W. : Plastic Surgery 679
Marsh, Elias J. : Abell Commission Report 62
Discussion of Ocular Muscle Abnormalities 926
Treasurer’s Annual Report Aug. Sup. 19
Treasurer’s Presessional Report 496
Martin, J. W. : Discussion of Fractures 13-14
Relation of Traumatic Surgery to Industry 6
Marcus, Joseph H. : Clinical Evaluation of a Concen-
trate of Vitamins A and D S50
Discussion of Clinical Evaluation of a Concentrate
of Vitamins A and D 853
Marcus, Joseph M. : The Gastro-Intestinal Patient 90
Mark, Joseph S. : Differential Diagnosis of Lead Poi-
soning 334
Prevention and Control of Lead Poisoning in In-
dustry 773
Marvel, Philip, Jr.: Cardiac Irregularities 903
Discussion of Cardiac Irregularities and Silent Mitral
Stenosis 913
Mengel, Willard G. : Squint in Childhood and Its Ef-
fect in Later Life 700
Miller, D. J. M. : Discussion of Non-Pathologic Heart
Murmurs in Children 103
Morrison, J. Bennett: An Historical Sketch of Develop-
ment of Preventive Medicine in New Jersey 731
Discussion of Fractures 10
Discussion of Symposium on Public Health Work.. 206
Newcomb, M. W. : Discussion of Pedographic Impres-
sions in School Children 931
Nichols. Stanley H. : Discussion of Clinical Evaluation
of a Concentrate of Vitamins A and D 853
Discussion of Integration of the Child 109
Discussion of Non-Pathologic Heart Murmurs in
Children 102
Nicholson, Percival: Discussion of Eczema in Infancy 227
Discussion of Essentials in Infant Feeding 217
Discussion of Gastro-Intestinal Disorders 20
Essentials in Infant Feeding 212
North, Harry R.: Finance and Budget Committee Re-
Okin, Irving: Discussion of Nipn- Pathologic Heart
Murmurs in Children 103
Non-Pathologic or Functional Heart Murmurs in
Children 100
Orr, Thomas G. : Culture 581
Osmun, L. Cook: Councilor District Meeting 63
Paddock, Royce: The Dust and Bacterial Factors in
Asthma 687
Pannell, W. L. : Some Oddities in Acute Mastoid Dis-
ease 22
Parsonnet, Aaron E. : Myocardosis; The Failing Heart
of Middle Life 831
Treatment of Acute Coronary Thrombosis 296
Parsons, William Barclay: Indications for Surgery in
Diseases of the Thyroid 431
Patterson, Ross V.: Our Responsibility for Public Edu-
cation Regarding Comparative Costs of Sickness... 585
Peacock, Robert: Discussion of Symposium on Pub.ic
Health Work 207
The Doctor and the Law 203
Peer, Lyndon A.: Asthma from the Standpoint of the
Rhinologist 692
Tube Flaps in Reconstructive -Surgery of the Face.. 86
Perlberg, Harry J. : A Few Thoughts in Therapy for
Ailing Medical Practice Neither New Nor Official.. 960
Filler, Jacob: Treatment of Active Measles by Intra-
muscular Injection of Recent Convalescent Whole
Blood 340
Pinneo, Frank W. : Discussion of Fractures 10
Discussion of Symposium on Public Health Work... 206
Preliminary Report of Health and Accident and
Automobile Insurance Committee 438
Regular Report of Health and Accident and Automo-
bile Insurance Committee Aug. Sup. 34
Polevski, Jacob: Discussion of Cardiac Irregularities
and Silent Mitral Stenosis 913
Discussion of Duodenal Tube Drainage of the Biliary
System 815
Relation of Arteriosclerosis to Cardiac Pathology.... 762
Significance and Diagnosis of Silent Mitral Stenosis 910
Some Sources of Information and Misinformation in
Cardiac Diagnosis 121
Pons, C. A. : Discussion of Fusospirochetal Disease of
the Lung 849
Fusospirochetal Disease of the Lung 834
Quigley, F. J. : Discussion of Symposium on Public
Health Work 207
INDEX
Read, Hilton S. : Constipation 755
Danger Ahead in the Cathartic Habit 660
Reik, Henry O. : Automobiles More Deadly Than War 148
Discussion of Symposium on Public Health Work.... 207
Editorials (see list)
Lighthouse Observations (see list)
Presessional Report of Editor and Executive Secre-
tary 439
Regular Annual Report of Editor and Executive Sec-
retary Aug. Sup. 6
Reports to Welfare Committee 64, 65, 363
Reviews of Books for Collateral Reading:
Biologic Basis of Human Nature — H. S. Jennings 145
Clinical Interpretations of Blood Examinations —
Robert A. Kilduffe 433
Doctor and Patient — F. W. Peabody 360
Easier Motherhood — Constance L. Todd 433
Noguchi — Gustav Eckstein 778
Our New Progress — James Bayard Clark 361
Paris and All the World Besides — Robert M. Keeley 433
.Soviet Russia — William Henry Chamberlin 361
Women and Monks— Joseph Kalinikov ... . 361
State Medicine in England 246
State Medicine in France 354
State Medicine in Other Countries 427
Travel Talks, with Medical Observations 42. 135. ?16, 354, 427
Reissman, Erwin: Looking at the Facts in the High
Cost of Medical Care 854
Rodman, E. W. : Consideration of the Causes of Diar-
rhea 548
Rosenberg, L. Charles: Discussion of Essentials in In-
fant Feeding 217
Discussion of Malnutrition in Children 212
Malnutrition in Children 208
Ross, William H.: Obligations of Professional Medical
Service 159
Report of Governor Roosevelt’s Commission to De-
vise a Public Health Program 508
The Open Hospital 51
Rothschild, Karl A.: One Year of Neurologic Service.. 47S
Rubinow, S. : Some Thoughts on Medical Economics
and Medical Practice 238
SchafF, Royal A.: Acute Perforation of Peptic Ulcers 417
Schapiro, Joseph: Discussion of Pedographic Impres-
sions in School Children 931
Schiffmann. S. : Moses Maimonides — Physician and
Philosopher 750
Schulte. Herbert A.: Treatment of Perforated Peptic
Ulcer 421
Schwarz, Berthold T. D.: Short History of Diphtheria
Eradication 529
Scott, James Ralph: Practical Management of Dia-
betes 304
Sherman, A. Russell- Observations in the Vienna Eye
Clinics 485
Sherman, E. S. : Discussion of Ocular Muscle Abnor-
malities 926
Shope, Pierce: Refraction and Health 69 7
Silver, H. B. : Discussion of Clinical Evaluation of a
Concentrate of Vitamins A and D 853
Smith, Ellis: A Skin Test for Whooping Cough 236
Snedecor. S. T. : Discussion of Pedographic Impressions
in School Children 930-931
Discussion of the Physician’s Part in the Training
of Teachers 935-936
Sommer, George N. J. : Discussion of Symposium on
Public Health Work 207
Impressions of Annual Conference of Secretaries of
Constituent State Medical Associations, 1930 60
New Year Greetings 49
Presidential Address 539
Presidential Address to House of Delegates. . Aug. Sup. 1
Spencer, G. T. : Intradural Caudal Anesthesia 235
Sproul, O. IL: Memorial Tablet to Dr. O. H. Sproul... 110
Stalberg, Samuel: Discussion of Integration of the
Child ! 109
Stern, Arthur: Discussion of Diet in Eczema of Infants 222
Discussion of Whooping Cough 99
Stewart, Walter B.: The Cult of Asklepios 603
Stewart, W. Blair: Report of American College of
Physicians Meeting 513
Stokes, John II. : Preventing the Transmission of
Syphilis 391
Stokes, S. Emlen: The County Society 114
Subin, Harry: High Lights in the Life of Robert Koch 342
Sullivan, George F. : Discussion of Ocular Muscle Ab-
normalities 926
Talleson, H. M. : Are We Underpaid? 578
Taneyhill, Mrs. E. C. : Report of Field Secretary Aug. Sup. 24
Teeter, Charles E.: Cardiac Failure of the Congestive
Type 823
Toye. John E. : Discussion of Fractures 8
Wade, S. F. : Discussion of Duodenal Tube Drainage
of the Biliary System 814
Wallhauser, H. J. F. : Discussion of Eczema in Infancy 226
Warren, C. B. : Discussion of Pedographic Impressions
in School Children 930
Waters, Edward G.: pUn for Control of Special-
ism Aug. Sup. 41
Plan for County Society Control of Periodic Health
Examinations 956
Weber, F. C. : Bacterial Heart Failure 760
Weigel, Elmer P. : Discussion of Fractures 9-13-14
Wells. Walter A.: The Noises of Civilization and Their
Evil Effects 653
Wherry, E. G. : Discussion of Eczema in Infancy 227
Wile, Ira S. : Integration of the Child 103
Williams, F. E. : Mental Hygiene 60
Wolf, I. J. : Recent Advances in Acute Poliomyelitis. . 936
Wright. Harold Edwin: Pre-School and School Physi-
cal Examinations 61
Yaguda, Asher: Development cf a Postmortem Service 636
Yazujian, Dikran M.: Discussion of Tonsillectomy 30
Zehnder. Charles: Discussion of Ocular Muscle Abnor-
malities . ... 926
B
Board of Medical Examiners:
Annual Report Aug. Sup. 29
Reported Prosecutions 63, 516
Board of Trustees, Report Aug. Sup. 20-51
Budget Committee Report Aug. Sup. 20
Business Committee: Appointment of Aug. Sup. 14
Report of Aug. Sup. 45
C
Charter, Committee Report on Aug. Sup. 21
Child Health and Protection Aug. Sup. 12-48
COLLATERAL READING—
How’s Your Blood Pressure? 951
Noguchi i 778
On an Anthology of Chestnuts 254
Real and Unreal 712
Review of Some Medical Books 433
Santa Claus and New Books 145
Some New Books 360
The Future of Freud — William Healy, Augusta F.
Bronner, Anna Mae Bowers 52
The Immortal Lydia 664
Will Other Worlds Affect Our Health ? 870
COMMITTEE REPORTS—
Board of Trustees Aug. Sup. 20, 51
Business •> Aug. Sup. 45
Charter Aug. Sup. 21
Constitution and By-Laws Aug. Sup. 3-35
Defense and Indemnity Insurance Aug. Sup. 33
Delegates to American Medical Association .. Aug. Sup. 36
Editor and Executive Secretary Aug. Sup. 6
Field Secretary Aug. Sup. 24
Finance and Budget Aug. Sup. 20
Health, Accident and Automobile Insurance. .Aug. Sup. 34
Honorary Membership Aug. Sup. 28
Hospitals and Medical Education Aug. Sup. 33
Judicial Council Aug. Sup. 17
Nominations Aug. Sup. 49
Post-Graduate Education Aug. Sup. 30
Program and Arrangements Aug. Sup. 3-19
Publication Aug. Sup. 2
Scientific Work Aug. Sup. 2
Secretary , Aug. Sup. 4-14
State Board Medical Examiners .. Aug. Sup. 29
Treasurer Aug. Sup. 19
Welfare Committee Aug. Sup. 27
COMMUNICATIONS—
Abell Commission Report; Letter from Dr. Elias J.
Marsh 62
Active Immunization Against Measles 447
Additional District Health Officers 596
American Association for the Study of Goiter 172
American College of Physicians 517, 879
American College of Physicians Clinical Session 171
American Physiotherapy Association; Letter from Dr.
Harold D. Corbusier 63
An Interesting Item of History 675
Another Question of Ethics 675
Arc We Facing Social Control of Medical Practice?.. 674
Child Guidance — William Doody 595
Concerning Salt- Free Diet and Focal Infection 724
Councilor District Meeting; Letter from L. Cook
Osmun 63
Crippled Children’s Commission 975
Defense Against Malpractice Suits 596, 725
Errors in Official List 447
First Councilor District Meeting 447
Gorgas Prize to New Jersey Girl 596
How French Dentists Met the Insurance Question 723
How Practipedists Are Made 976
Important Notice Concerning Health and Accident In-
surance 976
INDEX
Impressions of Annual Conference of Secretaries of
Constituent State Medical Associations, 1930 — George
N. J. Sommer 60
Mental Hygiene; Letter from Dr. F. E. Williams 60
New Jersey Conference of Social Work 974
One Reason Why Patent Medicine Venders Thrive.. 445
Pre-School and School Physical Examinations; Letter
from Dr. Harold Edwin Wright 61
Society for the Relief of Widows and Orphans of Medi-
cal Men in New Jersey; Forty-ninth Annual Report 674
Survey of Chronic Illness in New Jersey 974
Violations of Medical Practice Act 63, 516
Walt Whitman Hotel 64
CONFERENCES—
Secretaries and Reporters of County Societies 956
Tristate Medical .. ,...148, 497, 585
Constitution and By-Laws Committee Report. .Aug. Sup. 3-35
Corrections 245
Errors in Official List 390, 447
Errors in The Journal 943
CURRENT EVENTS—
American College of Physicians 513
American Medical Association Convention 666
Dr. R. D. Freeman Lauded at Dinner 875
Fifth Councilor District Meeting 261
New Jersey Conference on Child Health and Protection 511
New' Jersey Tuberculosis League 874
Present Status State Society — Rutgers Post-Graduate
Course 259
Seventh Annual Conference of County Society Secre-
taries and Reporters 956
The Physician’s Economic Contribution to the Com-
munity—Charles Gordon Heyd 258
Urges Development of Posture Practice. Finds Cure
for Old Age 875
Welfare Committee Minutes 64, 65, 363
Would Elevate Chiropractic 875
D
Deafness— American Federation of Hard of Hearing 953
DEATHS—
Beatty, Henry Moore 990
Benjamin, Dowling 84
Blair, James A 602
Blake, Duncan Williamson 286
Colhoun, Charles 390
Commorato, John 84
Craythorn, Charles J 538
Davis, Lester R 730
De Grofft, Eugene E 286
Demarest, Frederick F. C < 465
Donges, John W 390
Dowling, Charles E 898
Frazer, Thompson 898
Garrison, Biddle H 730, 794
Hedges, Benjamin Van Doren 83
Hunter, James J 601
Kitchen, J. M. W 286
Koch, Louis A ; 678
Lamson, William J 990
Lawrence, George W 465
Lindley, Charles L 538
Lockwood, Frank Wesley 730
McCormick, Daniel L 84
Madden, Walter 466
Mercer, Archibald 990
Moore, John H 186
Morse, George Vane 84
Osmun, Louis Cook 466
Paczkowski, Thaddeus . 898
Savoye, Richard G 186
Schureman. James Percy 538
Scott, George 466
Seibert, Raymond S 538
Simpsen, Maxwell S 990
Stratton, William N 538
Taggart, Thomas Dartnell 794
Van Mater, John H 730
Voorhees, Nathaniel Whitaker 602
Webster, D. King 466
Wilson, Norton L 950
Defense and Indemnity Insurance Aug. Sup. 33
DISCUSSION OF PAPERS—
A Case of Pseudo-Hermaphroditism 899
A Few Thoughts in Therapy for Ailing Medical Prac-
tice Neither New Nor Official 960
A Plan for County Society Control of Periodic Health
Examinations 956
Cardiac Irregularities 903
Cardiac Irregularities and Silent Mitral Stenosis 912
Changes in Human Rickets After Viosterol Therapy.. 21
Clinical Evaluation of a Concentrate of Vitamins A
and D 853
Clinical Management of Heterophoria 919
Combined Orthoptic and Operative Treatment of Con-
vergent Squint in Young Children 923
Diet in Eczema of Infants 222
Eczema in Infancy 226
Essentials in Infant Feeding 216
Forcible Extension in an Ankylosed Joint 914
Fractures 8
Fusospirochetal Disease of the Lung 849
Gastro-Intestinal Disorders 20
Integration of the Child 109
Is Group Medical Publicity Ethical? 1. 961
Local County Medical Society Publicity 962
Malnutrition in Children 211
Non- Pathologic or Functional Heart Murmurs in Chil-
dren 102
Ocular Muscle Abnormalities 926
Overlapping the Rectus Muscles for Correction of Stra-
bismus 915
Pedographic Impresions in School Children 930
Some Oddities in Acute Mastoid Disease 26
Symposium on Public Health Work 206
Surgical Aspects of Biliary Tract Disease 797
The Physician’s Part in the Training of Teachers 935
Tonsillectomy 30
Treatment of Whooping Cough 99
Value of Duodenal Tube Drainage of the Biliary Sys-
tem in the Treatment of Various Diseases of the
Liver 813
E
ECONOMICS—
Are We Underpaid? — H. M. Tolleson 578
Family Doctor’s Income in Relation to Preventive
Medicine 578
The Open Hospital — William H. Ross 51
Editor: Presessional Report of 439
Regular Annual Report of Aug. Sup. 6
EDITORIALS—
Adding Insult to Injury 133
Advance Notice of Annual Meeting 425
An Apt Phrasing of Medical Ethics 781
Asbury Park Convention 579
Automobiles More Deadly Than War 861
Control of Specialism 243
County Society Advertising 131
County Society and Hospital Reports 426
Crippled Children’s Commission 779
Doctors Are “Easy Marks’’! 351
Entering Upon a New Fiscal Year 580
Errors in the Journal 943
Fractures and the Compensation Law 49
Growing Importance of Mental Hygiene 780
In This Issue 245
Interesting Information Concerning Old Golds 493
Iowa Plan of Securing Payment for Services to the
Community's Indigent Sick 49
Legislation in the Making 245
Medical Service of the Future 132
Necessity for Vacations 661
Negotiating Loans for Medical Expenses 244
New Year Greetings — George N. J. Sommer 49
Newspaper Publicity j 713
Parlous Times 941
Personal Interest and Activity 353
Preliminary Announcement Regarding Post-Graduate
Medical Courses 863
Revision of Public Health Laws 714
State Medicine 352
Status of State Medicine 426
Study of State Medicine 662
The Official Transactions 661
The Passing Westward of Osmun and Lawrence 425
The Physician an Idealist 352
What Price Football! 942
Workman’s Compensation Law 713, 863
Election of Officers Aug. Sup. 49
ESTHETICS—
Appreciation of Good Music 254
Consider the Dreamer 360
Culture — Thomas G. Orr 581
Make Your Own Murals 494
Music in Relation to Art and Life 54
Musical Matters of Interest to Physicians 868
Phlebitis — E. S. Corson 142
Recognition of Home Talent 141
INDEX
Requiem to the Unknown Soldier — Ralph S. Cone 142
Roadside Esthetics ~8J
The War Nurse’s Story — Ralph S. Cone 141
The Windmill Orchestra Conductor , .... 717
ETHICS—
C’est Formidable L'Opiniou Publique 717
Character — Decent Conduct 782
Hurry, Hurry, Hurry! -. 952
Lowering of the Standard of Ethics 53
Medical Societies 581
More Health Ethics 143
Patients Must Not Be Neglected 432
Success 867
The Law Is an Ass .t., 663
The Physicians in Holy Writ 252
Times Square Has a Summer Visitor 663
Uphold Honor of the Profession 494
“Who Steals My Purse Steals Trash" 359
Executive Secretary:
Presessional Report of 439
Regular Annual Report of Aug. Sup. 6
Reports to the Welfare Committee 64, 65, 363
F
Field Secretary, Report of Aug. Sup. 24
G
Group Defense and Indenmnity Insurance Aug. Sup 33
Group Health and Accident and Automobile Insur-
ance Aug. Sup. 34
H
Hard of Hearing, American Federation of 953
House of Delegates, Transactions of Aug. Sup. 1-56
I
INSURANCE—
Defense and Indemnity Aug. Sup. 33
Health and Accident and Automobile — ..438, Aug. Sup 34
Important Notice Concerning Health and Accident In-
surance 976
J
Judicial Councilors, Reports of Aug. Sup. 17
L
Lighthouse Observations 55, 147, 148, 257, 441, 497, 583, 665,
666, 719, 720, 784, 872, 953
M
Maternal Welfare, Resolutions on . ,..Aug. Sup. 42
Medical Defense and Indemnity Insurance ...... Aug. Sup. 33
Medical Examiners, Report of Prosecutions Aug. Sup. 9, 63, 516
Membership. Official List April Sup. 1-48
Mental Hygiene, Committee Report ....Aug. Sup. 48
N
New Jersey Conference on Child Health and Protection 511
Nominating Committee Report Aug. Sup. 49
O
OBSERVATIONS FROM THE LIGHTHOUSE—
Acute Hemorrhage from Corpus Luteum and Graafian
Follicle 665
American Federation of Organizations for the Hard of
Hearing 953
Combination Anesthesia 583
Diagnostic Relationship of Physician and Dentist...... 872
Head Injuries 441
Management of Angina Pectoris 597
Massage in Rehabilitation Work 148
Mental Hygiene and Industry . 720
Mental Hygiene and the Child 666
Practical Use of Spinal Anesthesia 719
Public Relations Committee 55
Rehabilitation of the Disabled 147
The Patient with Heart Disease 257
Vocal Cords of Metal 257
Why We Reach for That Sweet 784
Officers, Election of Aug. Sup. 49
Official Transactions, Annual Meeting ........ Aug. Sup. 1-86
ORIGINAL ARTICLES—
Acute Abdomen — John B. Deaver 407
Acute Perforation of Peptic Ulcers — Royal A. Schaff.. 417
A Doctor's Confession of Faith — Wells P. Eagleton 2S7
Advantages of General Anesthesia in Tonsillectomy —
William Campbell 29
A Group of Endocrine Cases — Frank J. T. Aitken 470
Alcoholic Pseudo- Pellagra — N. B. Heller 467
Anemia of Pregnancy — Robert A. Kilduffe 341
An Historical Sketch of Development of Preventive
Medicine in New Jersey— J. Bennett Morrison 731
Are We Underpaid? — H. M. Tolleson 578
A Romance of Paternalism — Walter F. Donaldson 587
A Skin Test for Whooping Cough — Charles V. Craster,
Ellis Smith 236
Asthma from the Standpoint of the Rhinologist — Lyn-
don A. Peer 692
Automobiles More Deadly Than War — Henry O. Reik 148
Bacterial Heart Failure — F. C. Weber 760
Bacteriologic Study of Chronic Infectious Arthritis —
John W. Gray, Cecil H. Gowen 38
Cardiac Failure of the Congestive Type — Charles E.
Teeter ■ 823
Changes in Human Rickets After Viosterol Therapy —
John Caffey 21
Child Guidance— William Doody 595
Child Hygiene — Julius Levy 694
Circulatory Disturbances in the Extremities of Dia-
betics— David W. Kramer 560
Clinical Evaluation of a Concentrate of Vitamins A
and D — Joseph H. Marcus 850
Clinical Significance of High and Low Blood Pressure —
R. Burton Opitz 302
Common Conditions in Industrial Ophthalmology —
George J. Dublin 7C4
Common Diseases of the Oral Mucosa — Bart M. James 563
Consideration of the Causes of Diarrhea — E. W. Rod-
man 548
Constipation — Hilton S. Read 755
Continued Education of the Doctor — John A. Hartwell. 639
Councilor District Meetings — Dr. Snedecor 506
County Society — S. Emlen Stokes 114
Cult of Askiepios — Walter B. Stewart 603
Culture — Thomas G. Orr 581
Danger Ahead in the Cathartic Habit — Hilton S. Read 660
Development of a Postmortem Service— Asher Yaguda 636
Development of Public Welfare Work — William J. Ellis 187
Diabetes Mcllitus and Thrombo angiitis Obliteians in
the Same Patient — Harold S. Davidson 570
Diet in Eczema of Infants — F. I. Krauss 217
Differential Diagnosis of Lead Poisoning — Joseph S.
Mark 334
Doctor and the Law — Robert Peacock 203
Duodenal Stasis — Charles Frederick Baker 1
Dust and Bacterial Factors in Asthma — Royce Paddock 687
Eczema in Infancy — F. J. McCauley 223
Essentials in Infant Feeding — Percival Nicholson 212
Etiology, Diagnosis and Treatment of Peptic Ulcer —
George H. Lathrope 344
Factors in the Early Diagnosis and Treatment of Frac-
tured Skulls — H. Wesley Jack 608
Female Sex Hormone — Rita S. Finkler 766
Foreign Body in the Urinary Bladder — R. L. McKier-
nan, H. H. Goldstein 709
Fungus Infection of the Skin — S. J. Fanburg 92
Fusospirochetal Disease of the Lung — F- J- Altschul,
C. A. Pons, W. G. Herrman 834
Gastro-Intestinal Disorders — Charles Gilmore Kerley.. 14
Gastro-Intestinal Patient — Joseph M. Marcus 90
Generla Practitioner and Obstetrics — Samuel A. Cos-
grove 545
Health Department Growth in New Jersey — D. C.
Bowen 196
Hereditary Epistaxis — Hyman I. Goldstein 309
High Lights in the Life of Robert Koch — Harry Subin 342
Indications for Surgery in Diseases of the Thyroid-
William Barclay Parsons 481
Influence of Public Health Activities on Medical Prac-
tice— Julius Levy 193
Integration of the Child — Ira S. Wile 103
Intradural Caudal Anesthesia — G. T. Spencer 235
Leukorrhea- P. Brooke Bland 489
Liver Cysts— John II. Hermann, Guy B. Griffin 337
Looking at the F'acts in the High Cost of Medical
Care — Erwin Reissman 854
Malnutrition in Children— L. Charles Rosenberg 208
Medical Ethics — Harry H. Bowles 35
Medical Possibilities of Sea Water — C. L. DeMeritt... 706
Medical Service of the Future — G. W. Haigh 115
Medicolegal Aspects of Disability in Industrial Lead
Poisoning — Max Kumme! 327
Memorial Tablet to Dr. O. H. Sproul — John F. Hagerty 110
Modern Treatment of Varicose Veins — V. Earl Johnson 229
Moses Maimonides — Physician and Philosopher — S.
Schiffmann 750
Myocardosis; The Failing Heart of Middle Life — Aaron
E. Parsonnet, Albert S. Hyman 831
New Method of Outlining the Heart, Its Chambers
and Great Vessels — Clyde M. Fish 817
Noises of Civilization and Their Evil Effects — Walter
A. Wells 653
Non -Pathologic or Functional Heart Murmurs in Chil-
dren— Irving Okin 100
Obligations of Professional Medical Service — William
H. Ross 159
INDEX
Obstetric Mortality — J. C. Hartman 31
Observations in the Vienna Eye Clinics— A. Russell
Sherman 485
Occupational Dermatitis — John E. Kiley 613
One Year of Neurologic Service — Karl Rothschild 478
Our Responsibility for Public Education Regarding
Comparative Costs of Sickness— Ross V. Patterson.. 585
Pedographic Impressions in School Children — Donald B.
Hull 928
Physicians’ Economic Contribution to the Commun-
ity— Charles Gordon Heyd 258
Physician's Part in the Training of Teachers — Grace
M. Kahrs 932
Plastic Surgery— Tacques W. Maliniak 679
Practical Gastro-Enterology — J. Gerendasy 768
Practical Management of Diabetes— James Ralph Scott 304
Practitioner’s View of Medical Economics — F. I. Krauss 743
Presidential Address — George N. J. Sommer 539
Prevention and Control of Lead Poisoning in Industry—
Joseph S. Mark 773
Preventing the Transmission of Syphilis— John H.
Stokes 39J
Prevention of Measles — George Heller 617
Public Relations as a Specific — John S. Irvin 959
Publicity, A Remedy for Many Society Froblems— R.
I. Downs 959
Radiographic Diagnosis of Gall-Biadder Pathology—
Louis J. Gelber 829
Recent Advances in Acute Poliomyelitis — I. J. Wolf. . 936
Recurring Postoperative Parotitis— Harold S.‘ Davidson 85
Refraction and Health — Pierce Shope ,. 697
Relation of Arteriosclerosis to Cardiac Pathology—
Jacob Polevski 753
Relation of Traumatic Surgery to Industry— J. W.
Martin ‘ g
Report of Governor Roosevelt’s Commission to De-
vise a Public Health Program— William H. Ross 508
Review of Recent Literature on Thrombo-angiitis Ob-
literans— Max Gross 57]
Rupture of Gastric Ulcer— Edward C. Klein, jr. 412
Short History of Diphtheria Eradication— BeHhold T.
D. Schwarz 539
Significance and Diagnosis of Silent Mitral Stenosis—
J. Polevski
910
Sinusitis — E. S. Hallinger 475
Some Difficulties of the Asthma Problem— George H7
Lathrope ^84
Some Oddities in Acute Mastoid Disease— W. L. Pan-
nell
22
Sciir,e s . Information and Misinformation in
Cardiac Diagnosis — Jacob Polevski 121
Some Thoughts on Medical Economics and Medical
Practice — S. Rubinow 218
Squint in Childhood and Its Effect in Later Life— Wii-
lard G. Mengel 700
State Department of Labor in Relation to the Public
and Medical Profession — Henry H. Kessler 200
Statistical Study of Diphtheria in Newark— Joseph
William Gardam ‘ g3g
Surgical Aspects of Biliary Tract Disease-^- John B
Deav«
795
Thrombosis and Embolism — Frederic W. Bancroft 619
Tonsillectomy bv Diathermy— A. S. V. Giglio 771
Tonsillectomy Under Local Anesthesia— Robert H
Fowler 27
Treatment of Active Measles by Intramuscular Injec-
tion of Recent Convalescent Whole Blood— Jacob Filler 340
Treatment of Acute Coronary Thrombosis— Albert S.
Hyman, Aaron E. Parsonnet 396
Treatment of Bight’s Disease— Rolfo Floyd 55?
Treatment of Perforated Peptic Ulcer— Herbert A.
Schulte 40J
Treatment of_ Whooping Cough— A.' ' S.' ’ Fi’n’keistein .' 96
Tube Flaps in Reconstructive Surgery of the Face—
Lyndon A. Peer gg
Useful Irrigating Fluid for Septic Wounds— H. h! Gold-
492
819
Uterine Hemorrhage Radiologically Considered— W. G
Iierrman
Value of Blood Sedimentation Test in Gynecology
John Huberman 403
Value of Duodenal Tube Drainage of the Biliary Sys-
tem in the Treatment of Diseases and Disorders of
the Liver — B. B. Vincent Lyon 799
What Are State Departments of Labor Doing to Ad-
vance Industrial Surgery ?— Round Table Discussion. 498
What Is Wrong with the Fracture Situation ?— J. K.
Adams j
What the Present Day Public Thinks’ ' of' 'the ' Medical
PERSONAL ITEMS—
POEMS—
De Profundis 242
Don’t Quit ; 777
Phlebitis — E. S. Corson 142
Requiem to the Unknown Soldier— Ralph S. Cone ..... 142
September 712
The Bell Buoy — Ralph S. Cone 577
The Love of Books 859
The War Nurse’s Story — Ralph S. Cone 1 141
Today 41
POST-GRADUATE EDUCATION—
Preliminary Announcement Regarding Post-Graduate
Medical Courses 863
Committee Report • Aug. Sup. 30
Preliminary Program of. Annual Meeting 435-441
Pre-School Child, Medical Care of . ...Aug. Sup, 50
President: Annual Address of 539
Opening Address to House of Delegates Aug. Sup. 1
PRESESSIONAL REPORTS—
Committee on Health and Accident and Automobile
Insurance 438
Editor and Executive Secretary 439
Treasurer 496
Welfare Committee , 438
PROGRAM AND ARRANGEMENTS—
Annual Report : ..-. .Aug. Sup. 3-19
Preliminary Report 435-441
PUBLIC RELATIONS—
Agree Not to Publish Doubtful Advertising . 876
Announcement of the First Award Under the Thomas
W. Salmon Memorial 263
A “White Collar” Hospital That Is Proving the Case 514
Bill No. 304 Abell’s 57
Consultation Service at Mt. Sinai Hospital for People
of Moderate Means 721
Control of Proprietary Medicine 514
: Copyright Glasses ;..... 972
Disclosure of Diseases Under Prohibition Act Abolished 261
Doctor’s Dilemma 878
Future of Surgery 723
Generosity Runs Riot 722
Governor Looks at Chiropractic 442
Hold Free Foot Clinic in Resort This Week 878
How Science Nipped an Epidemic 169
“In a Heluva Fix” .-... 972
Infant Mortality Lowest in History 57
Leadership in Medicine 878
Legal Voluntary Euthanasia 972
Male Prostitute Convicted 720
Measurement of Noise 784
Medical Cowards 722
More Persons in Mental Than in General Hospitals.. 671
New Jersey Pharmaceutical Convention 671
Newark Tops Class in Health Rating 442
Noisy Ambulances 970
Report to the Commissioner , of Labor by the Work-
man’s Compensation Advisory Commission .... 442
Smith Urges Clinics or Health Insurance , 877
Staging a Health Drive Among Pre-School Children.. 672
State Medicine and Control of Specialism 168
Surgeons Reduce Fees 57
The Hoe, a Cure for Crime 971
The New England Medical Center 262
The Supertrained Nurse 672
Tobacco 875
Vaccination Favored to Prevent -Diphtheria 877
Warning to Physicians 261
White House Conference on Child Health and Protec-
tion 58
PUBLICATION COMMITTEE—
Annual Report of Aug. Sup. 2
R
RESOLUTIONS—
Committee to Study Status iof State Medicine .Aug. Sup. 47
False and Misleading Advertisements Aug. Sup. 47
Maternal Welfare Aug. Sup. 42
Medical Care of Pre-School Child Aug. Sup. 50
Medical Care of School Children Aug. Sup. 43
Mental Hygiene Aug. Sup. 48
Motor Vehicle Accidents Aug. Sup. 48
Prohibition ; Aug. Sup. 5
Specialists and Specialism Aug. Sup. 37
Jan., xxiii. ; Feb., xxviii.; Mar., xxi.; Apr., xxi.; May,
XXI.; June xxi.; July, xxi.; Aug., xxi.; Sept., xiv.;
Oct., xiv.; Nov. xiv.
S
SCHOOL CHILDREN—
Medical Care of
Aug. Sup. 43
INDEX
SCHOOL HEALTH DEPARTMENT—
Cafeteria and Luncheon 785
Clippings 723
Minimum Bibliography for School' Physicians 515
Notes from Los Angeles 444
Notes of General Interest 365
Physician’s Part in Hygiene and Sanitation of the
School Building 879
Pupil Supervision 673
School Physician’s Part in Health Education 973
Special Meeting of School Physicians 263
Standards for Prevention and Control of Contagious
Diseases 169
Suggested List of Activities for School Physicians 597
School Health Work — Request of Dr. Ireland. .Aug. Sup. 35
School Physicians, Section of ! Aug. Sup. 62
Scientific Work, Report of Committee Aug. Sup. 2
Secretary: Annual Report Aug. Sup. 4-14
Secretaries and Reporters of County Societies. Annual
Conference 956
SOCIETY REPORTS—
Councilor District Meetings:
Councilor District Meeting 63
First Councilor District Meeting 276
Second Councilor District 522
Third Councilor District 894
Fifth Councilor District 450
Round Table Discussion of 506
County Medical Societies:
Atlantic 71, 175, 268, 370, 450, 519. 883, 978
Bergen 73, 178, 271, 375, 450, 522, 791, 885, 979
Burlington 271, 376, 523 , 782, 980
Camden 73, 178 , 272, 377 , 451, 524, 886, 982
Cape May 982
Cumberland 179, 451, 678, 886
Essex 73, 179, 272, 377, 451, 524, 886, 982
Gloucester 74, 179. 277 , 382 , 454 , 526, 793 . 888 , 983
Hudson 74. 180. 277, 382, 454, 526, 888
Hunterdon 184. 462, 987
Mercer 81, 184, 284 , 388, 462. 534 , 599. 893 , 988
Middlesex- 81, 184, 388, 463, 599, 895, 988
Monmouth 82, 285, 389, 463, 535, 599, 896
Morris :82, 185 , 389. 536, 600, 793 , 988
Ocean 163, 537, 988
Passaic 83, 185 , 285 , 390. 463 , 537 , 794, 896, 989
Salem 285, 464, 897
Somerset 285, 464, 600, 897
Sussex 286, 989
Union 185,464,678,897
Warren ...186, 537, 989
Local Societies:
Academy of Medicine of Northern New Tersey
381, 526, 888, 983
Eye, Ear. Nose and Throat Section
74, 179, 272, 379, 453, 525, 888, 983
Atlantic City Hospital Staff
71, 176, 268, 374, 520. 598, 677, 728, 788, 885, 979
Bayonne Hospital Clinical Conference. . 180, 283 , 461, 890, 987
Jersey City Medical Center 80, 460
North Hudson Hospital Clinical Society
77, 182, 383, 458, 531, 891, 984
Pine Rest Sanatorium 72
Rutgers Medical Club 82, 185, 388, 535, 599, 895
Summit Medical Society 185, 464, 537, 897
Westfield Medical Society 83, 898, 989
SPECIAL ARTICLES—
Medical Travel Talk — Henry O. Reik...42, 135, 246, 354, 427
Recent Visit to the Grenfell Mission on the Labrador-
Travel. Visit to Royal Victoria Hospital, Montreal—
John Hammond Bradshaw 715
John Hammond Bradshaw 864
Some Observations Upon Health Matters in England—
Henry O. Reik 944
SPECIALISTS AND SPECIAL1SM-
Plan for Control of Aug. Sup. 41
Resolutions on Aug. Sup. 37
STATE HEALTH DEPARTMENT—
District Health Officers 597
Laboratory Tests in Undulant Fever 366
Narcotic Control 516
Pasteurization of Milk 170
Spotted Fever 673
State Health Laws 59
State Medicine, Committee to Study Aug. Sup. 47
T
Transactions, Annual Meeting Aug. Sup. 1-86
Travel Article: A Visit to the Royal Victoria Hospital,
Montreal 715
Treasurer, Annual Report Aug. Sup. 19
Presessional Report 496
Tristate Medical Conferences 148, 497, 585
Trustees: Annual Report Aug. Sup. 20-51
W
WELFARE COMMITTEE—
Annual Report Aug. Sup. 27
Minutes of November Meeting 64
Minutes of December Meeting 65
Minutes of March Meeting 363
Presessional Report of 438
WOMAN’S AUXILIARY—
Adulteration of Foods 879
Annual Meeting, Minutes of Aug. Sup. 63-86
Annual Meeting, Transactions of Aug. Sup. 63-86
A Task Proposed for the Auxiliary 726
Attention Ladies 172
Executive Board Meeting 448, 881, 976
Note from the Editor 367
Panoramic View of the Woman’s Auxiliary to the
American Medical Association 172, 367, 598, 676
Preliminary Program Woman’s Auxiliary to the Ameri-
can Medical Association 173
Society for Relief of Widows and Orphans of Medical
Men of New Jersey — Edward J. Ill 69
State Society Auxiliary 70, 173
Winning Them Over 70
Woman’s Auxiliary A. M. A. Ninth Annual Conven-
tion 517
Woman’s Auxiliary to the American Medical Asso-
ciation 786, 977
Woman’s Part in Medical History. Jane Todd Craw-
ford— The Model Patient 264
Women at the A. M. A. Philadelphia June Meeting.. 448
County Reports:
Atlantic 174, 266, 369, 518
Bergen 70, 369
Burlington 881
Camden 174
Essex 174, 266, 369, 881, 977
Gloucester 70, 266, 369 , 449, 519, 881, 977
Hudson 70, 267, 370, 449, 787, 882, 978
Hunterdon 449, 978
Mercer 267, 519, 978
Ocean 267, 882
Passaic 174
Somerset 175, 370, 882
Union 175, 267, 370, 449, 727, 882
Workman’s Compensation and Contract Practice, Com-
mittee on Aug. Sup. 45
Journal of The M edical Society of New J ersey
Published on
die First Day of Every Month
Under the Direction
of the Committee on Publication
Vol. XXVIII., No. 1 ORANGE, N. J„ JANUARY, 1930 Y“r
DUODENAL STASIS*
Charles Frederick Baker, M.D.,
Newark, N. J.
Duodenal stasis is undoubtedly much more
frequent than was formerly recognized. That
it may be the cause of symptoms which we
have been prone to lay to diseases of the ap-
pendix and gall-bladder is a possibility with
which we must reckon, for operations upon
those organs do give relief, unless coincidently
the factors producing duodenal stasis are rec-
ognized and, so far as possible, corrected.
The causes of duodenal stasis may produce
continuous or intermittent effects. Those
producing continuous mechanical obstruction
and interference with normal duodenal mo-
tility may be extrinsic or intrinsic. The ex-
trinsic are peritoneal bands resulting from
cholecystitis ; anomalies of the pancreas in-
cluding tumors or annular pancreas ; compres-
sion by the superior mesenteric or other ar-
teries in the mesenteric root, behind which lies
the horizontal portion of the duodenum ; gas-
troptosis and ptosis of the colon and small in-
testine. The intrinsic causes include anom-
alies of duodenum, size and position; ulcer;
tumors ; etc. Those producing intermittent or
temporary stenosis are attributed by some to
neuromuscular derangement ; by others to su-
perior mesenteric artery compression accom-
panying right-sided ptosis or ptosis of the
small intestine. Conceivably, a drag upon the
♦(Read at the 164th Annual Meeting of the
Medical Society of New Jersey, Atlantic City, June
13, 1930.)
mesentery, producing intermittent stasis, may
follow periods of atonicity during severe
physical and nervous depression, particularly
with overloading of a low cecum and conse-
quent increased dragging upon its support ;
whereas, when, following rest or general re-
laxation a better tone develops, an improve-
ment would occur.
Ptosis of the stomach, by a dragging down-
ward of the upper portion of the duodenum,
causes an unusual angulation of the upper-
third of the descending portion, with stenosis
and dilatation. Inflammatory bands, result-
ing from cholecystitis and periduodenitis fol-
lowing ulcer, as well as anomalous develop-
ment of the peritoneum or failure of absorp-
tion of embryonal peritoneum, affect the
lower angle or junction of descending and
horizontal portions. Pressure by the superior
mesenteric or other branches which leave it
or the aorta at about the same level, gener-
ally produce dilatation and stenosis in the
horizontal portion. Inflammatory bands be-
tween the duodenum and jejunum at the duo-
denojejunal angle are generally the causative
factor in stenosis of the ascending portion.
The superior mesenteric artery leaves the
aorta above the horizontal portion of the duo-
denum, which it crosses, and gives off the
midcolic, right colic, ileocolic and terminal
branches to the small intestine. Many anom-
alies occur in this as in other anatomic
structures.
As stated by Kellogg: “The arterial walls
possess little elasticity as compared to the tis-
sues which surround them and when the or-
gans to which the arteries are distributed be-
2
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
come prolapsed, the latter become their chief
support and may compress the duodenum.
For this reason, prolapse of the small intes-
tine compresses the third duodenal segment,
by a direct pull upon the superior mesenteric
artery, providing the prolapse is not sufficient
to permit the intestines to rest upon the pelvic
floor. Prolapse of the cecum drags upon the
ileocolic, and through it on the superior mes-
enteric, causing compression at the same
point. With descent of the hepatic flexure,
the right colic, when it crosses the duodenum,
compresses the second or third segments
proximal to the mesenteric root. More than
one artery may be involved and (this is im-
portant) a combination of arterial compres-
sion and congenital or acquired bands is com-
mon.”
Symptomatology. The symptoms are due to
the mechanism of obstruction and to the tox-
emia, which is severe in direct proportion to
its proximity to the pylorus. From the ob-
struction we find nausea or vomiting. The
latter may be either spontaneous or forced, to
obtain relief, and occurring or produced after
a relatively short period following reception
of food into the stomach; pain in the upper
abdomen, either to the right or left of the
median line, and often deep and referred to
the back as in cholecystic disease; it may also
radiate to the shoulders. The pain may be
very severe or there may be complete absence
of this symptom. It may be relieved by pos-
ture, particularly if a change of position re-
lieves a drag of the prolapsed intestine. These
symptoms may be worse when the cecum is
over-full and constipation is present. If the
compression affects the region of the ampulla
of Vater, secondary effects may be present in
the liver, with enlargement and increased
sensitivity of both liver and gall-bladder.
I he toxic effects are more or less of a mi-
graine character: so-called bilious attacks
which may have originated in childhood,
ushered in by marked constipation and head-
aches ; disturbance of mental processes ;
severe physical depression ; disturbed heart
action ; poor peripheral circulation ; hyper and
paresthesias ; skin eruptions ; subnormal tem-
peratures and blood pressure, most of which
arc typical of toxemias in general.
Physical examination may reveal unusual
tenderness along the course of the duodenum,
;f it is distended, and a tympanitic note may
be found behind the right rectus muscle to the
right of and below the pylorus between the
liver and transverse colon. Duodenal succes-
sion may be elicited. Pressure may sometimes
empty the duodenum and the gas may be
heard as it rushes into the jejunum; follow-
ing which the area of tympany disappears.
The Roentgen-ray examination may easily
settle the diagnosis but when the cause lies
chief!} in mesenteric compression a negative
report is common. The reason for this is
that the mechanism may not always operate
to produce partial obstruction, with delay in
the passage of the barium content through the
duodenum, and peristalsis may at the time of
the examination be excellent. Improved peri-
stalsis may result from a rest period of a
few days or weeks preceding the x-ray ex-
amination ; or a cathartic the day before may
so improve peristalsis that stasis is overcome.
1 he radiograph may reveal varying degrees
of stasis from simple lagging in the flow of
the intestinal contents to complete stoppage.
The normal current through this organ is so
rapid that a true intestinal outline of the duo-
denum is never seen, unless delay exists. The
barium shadows appear as mere flecks dis-
seminated along its course. As the barium
mixture distends the dilated duodenum,
valvulae conniventes appear, which under or-
dinary circumstances are generally first recog-
nized in the upper jejunum. Hence, any
films showing a distinct intestinal outline, in
the regions of the descending or horizontal
portions, should at once intrigue us into care-
ful analysis of Roentgen and physical find-
ings and symptomatology, to see if we can-
not unravel the mysterious cause of a chronic
dyspepsia which may have bothered the pa-
tient for a considerable time and for which
he may have already been operated upon with-
out relief.
In cases showing greater dilation in the
more obstructive lesions, the signs are so ap-
parent that literally one who runs may read
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
3
the findings. The duodenum may be 2 or 3
times its normal diameter, and the stomach
also dilated. Under the fluoroscope, the duo-
denum may be seen to writhe in spasm, and
waves of reverse peristalsis may be demon-
strated. It is held by some that fluoroscopy is
the method of choice in detection of this con-
dition. If it is not used many pictures should
be made with the patient in different postures,
at least the prone, oblique, lateral and vertical.
Treatment. Many cases are amenable to
the usual measures employed to relieve en-
teroptosis and intestinal stasis. Surgical
measures are indicated when medical fail to
relieve. Some are plainly surgical in the be-
ginning, notably those in which the duodenum
is greatly dilated or is causing frequent cop-
ious regurgitation of bile. Personally, I do
not feel that it is pertinent for the roentgen-
ologist to discuss the various surgical meas-
ures and will leave that to others.
WHAT IS WRONG WITH THE
FRACTURE SITUATION*
J. K. Adams, M.D..
East Orange, N. J.
Some well meaning persons suggested that
I read a paper on fractures in 15 minutes.
This seemed to me a good deal of a contract,
and I wrote the Secretary that 1 really did not
think I could do that, but that instead I might
make a few remarks on the fracture situation
in general, which perhaps might promote a
discussion. At any rate, I will promise you
one of the shortest papers that was ever read
before this society, if you want to call it a
paper.
It seems to me that there is something wrong
with the fracture situation, and that the great-
est trouble lies in the present arrangement of
services in our hospitals. I am assuming that
it is the earnest desire of each and every one
of us who treat these conditions to have the
hospital services so arranged that the patients
*(Read at the 164th Annual Meeting of the Medi-
cal Society of New Jersey, Atlantic City, June 14,
1930.)
will get the greatest benefit possible. It seems
to me that “rotating” services, where from
2 to 4 different men handle a case, do not give
the best results. The responsibility is divided.
The problems facing each man as he goes on
duty are not as clear cut and well defined as
they would be had he handled the case from
the beginning. This creates a situation that
is distressing to the patient and his relatives,
not to mention some of the doctors. A frac-
ture occurring the latter part of the month is
often delayed in receiving the attention it
should, in order that the man coming on duty
the first of the next month can handle it from
the beginning; and patients who should have
their casts or apparatus removed near the end
of a month are often left over to the first of
the next month for the man who originally
put the cast on to take over the case again. It
occurs to me that there is nothing stimulating
about such a service. It lacks interest and,
frequently, the functional results suffer. The
medical profession created this type of ser-
vice ; we created it, and it is up to us to get
rid of it. No one else is responsible. It seems
time for a change, and it has been changed in
many hospitals with very gratifying results.
As I see the problem, there are 3 things that
can be done :
(1) Have a service called a “Fracture
Service”, to be under the charge of one man
with as many assistants as the work requires.
The entire responsibility will be his and all
due credit will be his. He cannot pass the
buck to anyone. The compensation income
from such cases might be divided between the
Fracture Service Staff and hospital; that is,
if they want to divide it. What you do with
the money so derived does not matter much
because it amounts to an extremely small sum
to any one person. It could very well be
spent on equipment, which is not very ex-
pensive.
The head of such service should spend at
least 2 weeks each year in visiting first class
bone clinics, actively studying the manner in
which they are treating these cases, and should
upon returning read a written report to the
staff of his hospital.
(2) If the first method is not cared for, I
4
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
siiggcst the following : Let everyone treat the
fractures in the old way, but at the end of
the month, when a man goes off duty on
everything else, let him continue to treat the
fracture patients that he has been treating,
and to treat them continuously until they are
discharged. This method has the advantage
of No. 1 in placing responsibility where it
belongs, and it also prevents buck-passing.
Further, it prevents men saying their fractures
were taken from them.
(3) A “Traumatic Surgery Service” ab-
solutely continuous like No. 1 might be es-
tablished. This would prevent any quibbling
in a case where there is a minor fracture but
decided nerve, ligament or muscle injury.
There could be no misunderstanding as to
whose service the case belonged, and who
was to control treatment. It may interest
you to know that when the new Physicians’
and Surgeons’ Hospital was started in New
York it was decided to have a fracture ser-
vice, but that anyone of the staff who wished
could, by saying so, treat his proportion of
fractures, but he was required to finish every
case he started. I am told by the head of the
service that since that rule was made only 1
man has asked to treat such a case, and he
only asked once.
Is there anyone here who does not believe
that a properly organized fracture service by
men interested in the subject, and who are con-
tinuously working on it, will produce better
results than the old rotating type where
everyone tries to do everything?
The fracture equipment in many of our
hospitals is insufficient or poorly kept. This
chaotic state of affairs is often due to the fact
that the equipment is not under somebody’s
special supervision. There may be a closet
into which all fracture equipment is thrown;
a few old Thomas’ splints, some rope and per-
haps a few splints bought from some clever
salesman by the superintendent but which no
one would ever use. Such an assortment and
a few very poor Balkan frames may con-
stitute the entire equipment. The reason for
this is that no one was really interested in the
subject.
A physiotherapy department does not ex-
ist in some hospitals; massage and such trifles
are not used, and there is no gymnasium with
simple apparatus for restoring function.
Much of the required apparatus is very in-
expensive and could be made by a hospital
carpenter.
The following recommendations, then, oc-
cur to me: First, put the fracture service on
a sound basis, like the operating room. Make
some one absolutely responsible for its proper
functioning. Second, put in charge of the
equipment some one who will keep it under
lock and key, in a place where the apparatus
can be properly arranged and where it can be
found when needed.
There is an extraordinary impression all
over this country, and I guess wherever peo-
ple have fractures, that the one thing to be
accomplished is to get the two ends of a
broken bone to grow together. That is not
the most important point in treating frac-
tures. I will admit that getting union is a
very important detail in treatment of a frac-
ture, there is no question about that, but the
patient did not come to you because he had
a broken leg — that is not why he came — he
came to you because he had pain and loss of
the use of his leg. Now, when you' have a
man with, we will say, a very simple fracture
of the tibia, and you have put it in a cast after
it has been nicely aligned, and he is lying in
bed, you are not treating him, he is treating
himself. His fragments are in perfect align-
ment. he gets nice union, radiograph shows
that there is an excellent formation of
callus ; then you are going to begin to treat
him, if you do the right thing. You are
ready to go ahead and treat him after he has
been lying in bed for 3, 4 or 5 weeks. But
in most cases this does not happen. He is
discharged after the cast has been removed,
and no further treatment is given him. The
follow-up service in most hospitals is imper-
fect. There are a few hospitals of the better
class that have a good follow-up service and
know what these patients are doing. From
one hospital that boasts of its follow-up ser-
vice I have treated 6 fracture patients who
came out within the last 6 weeks, and none
of them ever saw the follow-up attendant.
Jan , 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
5
Put the fracture service on a sound basis,
gentlemen, like the operating room. Why
have you a decent operating room in your
hospitals? The Board of Governors did not
come to you, nor the Board of Trustees, nor
the Executive Committee and say, “we insist
on your having the most magnificent equip-
ment that we can force upon you”. They did
not say that ! Oh, no, they did not ! You went
to them and said, “We can’t do the kind of
work that has to be done in the hospital unless
we have something to do it with”. There are
no records in your staff minutes in 99% of
the hospitals in this country, showing that you
have ever intimated to the Board of Trustees
that you wanted anything special with which
to treat fractures. Go back and read over the
books and see when you requested them to
furnish you with apparatus that you really
-could do something with. It is not there.
Now, equipment is a very broad word as
applied to treatment of fractures. What do I
mean by equipment? I don’t mean that your
hospital should be supplied with a perfectly
stupendous collection of complicated me-
chanical splints, the last word in the brace-
maker’s art. That is not what I mean at all.
If you have any such collection as that, it is
-an admission by your staff that they don’t
know how to treat fractures, and that they
are going to use the brains of the brace-
maker instead of using their own. The best
fracture men that I know have no such ap-
paratus. The other day a bracemaker came
into my office with such a perfectly mag-
nificent splint, I mean it was such a perfectly
magnificent piece of mechanical excellence for
the forearm and wrist, including every joint
of the entire hand, wrist and elbow, that it
was a mechanical masterpiece. It cost, I
think, $35 or something like that. It was such
a splendid and perfect piece of mechanism
that, although I have no use for such a thing
at all, I almost bought it just to study its
mechanics. However, the great trouble with
all that kind of thing is that you are fitting
the patient to a mechanical appliance. That
is not what you want to do. It is the greatest
mistake under the sun to do this. When a
fellow practices medicine way out in the coun-
try and has no drug-store convenient, he has
to keep some medicines on hand, and it is
highly proper that he should; but for a man
in a big city, that has a large drug-store near
the office, it is another thing, It is foolish, when
a patient comes to his office, for him to go to
his closet saying, “Why, yes, I have just the
thing for you”. There is no splint, I don’t
care how expensive it is, how perfectly mag-
nificent from a mechanical standpoint, that
cannot be improved upon by a very few dol-
lars worth of plaster of Paris, a little wire
and a pruning knife. You can put it in any
desired position and make it fit.
What I mean, when I say equipment, is :
You do want some Balkan frames, whether
metal or wood is up to you ; the wooden frames
have one very decided objection — they are a
perfect nest for vermin. After you have used
one for a very long time, destroy it. Make
them out of cheap stuff. The vast majority
of them don’t have to be very heavily con-
structed. You don’t need a Balkan frame
made of 2x2 lumber if you are going to treat
a fracture of the little finger. One of the
very best Balkan frames I ever had was an
old bamboo fishing rod that I had used quite
often. It was 25 feet long, and it could be
tied to the head of the bed, pulled down and
tied in the desired position. If you are going to
do something in regard to lining up a pelvis
and getting the patient’s weight off the bed,
that is another thing; but you should have
in your hospital some type of bed or beds on
which the patient’s bowels can move without
moving the patient in any way. I am not a
salesman for the Zimmer Company, but I
have not seen any other bed like it for treating
fractured hips, pelves or spines.
You should have a good fracture table in
your hospital, and you want somebody in
charge of it who knows enough to oil it every
day ; and you want someone to sharpen the
plaster knives every day ; and someone who
understands the making of plaster bandages,
for they are very simply made, and it is a
frightful waste of money to buy them. A
nurse that knows how to do these things, who
has been brought up in the business, and
knows how to handle herself in a fracture
6
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
room, is an asset. We have one at the hospi-
tal for Crippled Children in Newark. She
will do a 5 yd. bandage in a minute, and she
will do it for ah hour without the slightest
trouble.
You need Balkan frames. If you are going
to use the metal ones, let me caution you
against having an electrocution. They are
splendid frames, they are absolutely vermin-
proof, but there are situations — unless you
keep the point in mind — where you may get
your high-tension line a little too near the
metal, and cause trouble.
That is all the equipment you need. It
does not cost much. Of course, you should
have physiotherapy, but don't have to have
any gorgeous display. Massage is necessary.
You want some diathermy. Those are the
2 main things you need, and if you have them
you can go a very long, way.
RELATION OF TRAUMATIC SURGERY
TO INDUSTRY*
J. W. Martin, M.D.,
Baltimore, Md.
Many interesting problems are arising be-
tween industry and our profession ; especially
is this true with traumatic surgery. These
problems are interesting because they deal
with facts facing our profession today and
which we must solve.
The date of conception of “industrial sur-
gery” is unknown ; its birth was unheralded
and its growth unnoticed, until the compensa-
tion laws went into effect. The British Par-
liament passed its Workmen’s Compensation
Act in 1897. This attracted the attention of
men in the United States who were interested
in labor problems ; and while several acts were
passed here which did not meet constitutional
requirements, it was not until 1911 that the
legislatures of Wisconsin and New Jersey
passed compensative laws of an effective
form. Since that time all the states except
* (Delivered at the I64th Annual Meeting of the
Medical Society of New Jersey, held at Atlantic
City, June 13, 1930.)
South Carolina, Florida, Mississippi and
Arkansas have adopted compensation laws;
and while there is a great variance in their
interpretation, it is the intention of all of
these laws to protect injured workmen and in-
dustry as well.
Since the various compensation laws went
into effect, the attention of the medical pro-
fession has been aroused because the laws
provide for the collection of accounts for
services rendered. This caused a competition
among doctors for the business and has had
a tendency to commercialize this branch of
surgery, with the result that the greater part
of this work has been thrown into the hands
of medical men who possess more business
sense than professional ability ; and industry
has found that for the interests of all con-
cerned it is necessary to endeavor to place in-
jured employees under the care of competent
surgeons and to establish control of all mat-
ters of a medical and surgical nature. Con-
sequently, there must come a complete and
definite understanding of this economic prob-
lem by industry, by commissioners of labor,
by labor organizations, and by the medical pro-
fession. Our profession is faced with the
responsibility of giving to injured workmen
efficient service at a reasonable price, and has
for its reward the saving of human wastage
and the avoidance of unnecessary deformities,
which mean so much to the injured, to say
nothing of the time saved and the large per-
centage of disability avoided. The indis-
criminate use of doctors means not only poor
end-results or prolonged disabilities for the
injured, but it is costly to industry.
The general handling of industrial surgery
requires more than surgical knowledge ; it re-
quires an interest in the work from the stand-
point of the employer, the employee and the
insurance carrier. The surgeon should be able
to make to the insurance carrier and to the
Commissioner of Labor true and firm state-
ments of a disability, without fear or favor.
A man might be a foremost surgeon in his com-
munity but if he does not cooperate in the
proper handling of compensation cases, he
will be practically worthless as a surgeon for
industry. Tt is a very hopeful sign that the-
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
7
best surgeons are beginning to give more of
their attention to surgery of the injured, which
means of course that the claimants under com-
pensation laws will receive a superior class of
service in the future. There are still many
weak points in the surgical treatment of com-
pensation cases.
Our profession is going through a very
close investigation by industry because our
end-results in the treatment of injured work-
men have not been satisfactory from an eco-
nomic standpoint; and if they have not been
satisfactory from an economic standpoint,
they have not been satisfactory from a humane
one, because these go hand in hand. Good
surgical results produce good economic re-
sults. Our profession is on the witness stand,
as it were, and industry is asking : “Why does
the same kind of a case show good results and
small expense in the hands of one physician,
and poor results and great expense in the
hands of another?” “Why do some cases re-
quire many office treatments and a great
amount of physiotherapy, while the same kind
of cases respond to fewer treatments and no
physiotherapy in the hands of another?”
Thousands of dollars are being paid for
hernias which, as the result of accident during
the course of employment, have' never ex-
isted. To illustrate, a man was acting as a
watchman and was being heckled by some
children. The history of the case states that
he jumped from behind a shed and said
“Boo”, causing him to have a double hernia;
and our organization was ordered to pay out
more than ,$300 in hospital and surgical
charges. The tendency to do open operations
when not indicated, cases of so-called trau-
matic appendicitis, and most interesting ex-
amples of sacro-iliac subluxation which have
Smith-Peterson or other fixation operations
performed, would fill a book and take all day
to talk about. Hospitals are authorized to
put injured employees in private rooms when
not necessary, to assign special nurses, and to
take x-ray pictures out of all reason. To
illustrate, a case was sent to a hospital with
a clinical history of a possible fracture of a
rib ; radiographs were taken of skull, spine,
and chest, the cost amounting to $75.
Much of the chaos found in the field of
traumatic surgery is due to the wide variance
of opinion ; and industry is asking why.
When a person is given to several physicians
to be examined, so that a true statement of
the man’s condition can be obtained, the re-
ports will show variations anywhere from
practically no disability to almost total disa-
bility. No wonder Commissions of Labor
have a tendency to ignore our recommenda-
tions and form opinions of their own ! I
firmly believe that every injured workman
should be given a liberal allowance for a dis-
abling injury; at the same time, if we are
to be responsible for the proper interpreta-
tions of those disabilities, our decisions should
lie made with a fair mind and a mature judg-
ment.
The term “aggravation of a preexisting
condition" is not thoroughly understood by
the laity and is capable of many interpreta-
tions. Shrewd lawyers have taken advantage
of this fact, and as a result this term is fre-
quently encountered in the trial of cases which
cannot stand on their own merits. For ex-
ample, instead of syphilis causing delayed
union of a fracture, it is claimed the accident
aggravated the syphilitic condition; instead of
rest in bed, following a back injury, improv-
ing the heart in a mitral insufficiency, it is
frequently argued that the general devitaliza-
tion of the body tissue as a result of the acci-
dent has aggravated the heart condition which
existed prior to the accident. This phrase
also benefits the malingerer; we may be mor-
ally certain that the patient is not as disabled
as he claims, but the Court says the burden of
proof rests upon us. Unfortunately, the mal-
ingerer is usually able to find some physician
who is willing to support his claim; as a re-
sult there is the usual difference in profes-
sional opinion, the Court becomes bewildered
when it finds 2 exactly opposite interpreta-
tions of the issue, and the general public be-
comes convinced that the medical profession
wears its dignity merely to camouflage its ig-
norance; for disagreement is always inter-
preted as ignorance. Unless our profession
confines itself to facts and accepted principles
rather than the competitive juggling of
s
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
theories and possibilities, our opinions will be
little heeded and we will lose the respect of
the public.
However, the poor end-results being ob-
tained for the injured workmen present our
greatest problem. Much of this is due to the
carelessness and indifference with which a
large part of our profession regards compensa-
tion cases. Men who lack special training will
attempt to handle injuries coming under the
compensation law which they would be afraid
to treat in their own private practice. A doc-
tor should know his limitations and should be
conscientious enough to immediately call a con-
sultant, specially trained, just as he would in
his own private work; for we all know what
procrastination means. As Scudder said in
his oration on fractures: “By treating a frac-
ture instantly, you treat the fracture; by
treating the fracture after delay you treat
complications. Early treatment is easy, de-
layed treatment is difficult and dangerous, late
treatment is lamentable.’’
During the past year we have also found
many cases in which there has been improper
treatment of simple wounds. The principles
of proper dressings have been neglected. Oint-
ments have been used on clean lacerations,
making a clean wound infected. Suppurating
wounds have been sealed by tight, dry, band-
ages. Anti-tetanus serum has been neglected.
Indifferent treatment has been given fractured
fingers and toes, causing unnecessary disa-
bilities and deformities. Injuries to soft
parts, such as nerve injuries and the cardinal
symptoms of acute abdominal conditions, have
not been recognized. During the past year
we have had several cases in which proper
diagnosis of a severed median or ulnar nerve
was not made. To my knowledge there have
been 4. cases of “acute abdomen” where the
patient’s life might have been saved if proper
diagnosis had been made and immediate ac-
tion taken.
We cannot help but realize that the chief
failure in our treatment of industrial injuries
comes from indifference, incompetence, and
delay ; and the solution lies in doing honest,
efficient work. It is no longer considered
•economy to organize a staff of surgeons on
a basis of low fees. There is a sincere desire
to give to the industrially injured the highest
grade of surgical care that can be secured.
Personally, I am not interested in fee sched-
ides ; but I am interested in seeing that
proper and efficient work is being done. For
if we are doing honest work, then that work
should be paid for by industry in proportion
to what the injured workman could pay if he
were a private patient. Industry should and
will pay for such service, regardless of fee
schedules or limits of compensation laws ; for
naturally if good work is done for the injured,
the amount of disability is lessened and in-
dustry and insurance carriers profit by it.
I will welcome the day when every state
in the union will provide for unlimited medi-
cal attention in its compensation law, with
proper surgical supervision, and when there
will be appointed to every Commission of
Labor outstanding medical men to act in an
advisory capacity without fear or favor in
connection with the care of the injured, the
estimating of disabilities, and the disposition
of controverted bills. 1 am happy to state
that the best men of our profession are inter-
ested in the solution of this problem. None
of us wants to see future medicine controlled
by state laws ; and as our profession in the
past has been respected and honored for its
high ideals, I am sure that industry, Com-
missions of Labor and the public will not be
mistaken in the confidence placed in us to
solve this economic problem.
Discussion
Dr. John E. Toye (Arlington): It strikes me that
fracture work has become a highly specialized
specialty and calls for a great deal of time. It
calls for more time and more patience than the
average general surgeon has to put into it. The
average general surgeon looks for results and
wants them quickly. He has been trained to
action. He has not been trained to wait. The
average fracture man, or bone surgeon, or ortho-
pedist is trained to wait and take an abundance
of time. For that reason I think the hospital’s
fracture service should be a distinct and separate
service, not because the rotating service is all
wrong, but because of the time a man may be
willing to put into it. As Dr. Adams has said,
when you have put the bones to something near
apposition, you have still done practically nothing
to rehabilitate that man, and the object of frac-
ture treatment is to get that man back on a wage-
earning basis as nearly as possible to that which
he enjoyed before. There is where time comes in.
It is easy enough to put fixation on and wait for
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
9
the bone to heal; but then your time, your patience
and your ingenuity are called upon to put that
man back on a wage-earning basis.
Just a word about physiotherapy: Until the
general surgeon, who is doing fracture work, or
doing industrial surgery or traumatic surgery, as
you choose, follows it up as a thing worth while,
physiotherapy is in danger of coming into disre-
pute and falling into the hands of charlatans. It
is in disrepute now; there is no question about
that. Many people will say, “I have a lamp, I
can take care of that at home”, which is utter rot.
Of course, use of heat is a means to an end, but
your massage and your constant follow-up are the
means of rehabilitation of the injured man.
I would like to follow Dr. Martin with a word.
This is apparently going to be a “panning” party
anyhow, and just now I am going to “pan” in-
dustry, or the insurance companies through in-
dustry. Dr. Martin said that industry is willing
to pay. In my observation industry has not been
willing to pay. It has delegated responsibility for
the injured workman to the insurance companies,
and the insurance companies have, by hook or by
crook, gotten rid of doing the best possible be-
cause they won’t pay the price. It is axiomatic
that you cannot get something for nothing. A
man who is doing special work, good conscientious
work, and attempting to rehabilitate injured work-
men, is not going to work for the fees which they
attempt to dictate. It is not at all unusual for me
to have a letter back from an insurance company,
after I have presented a bill, stating that “our fee
is — thus and so for this type of treatment”, but
that fee isn’t my fee; I can’t do that type of
work at that price, and until the insurance com-
pany is willing to recognize that it has to pay for
competent men — and it has to have competent
men to rehabilitate the injured workmen — it is
my contention that industry is not willing to pay.
Dr. E. P. Weigel (Plainfield) : I think both Dr.
Adams and Dr. Martin have opened for discussion
a subject which is rapidly becoming more acute
to all of us who engage from time to time in the
treatment of orthopedic or traumatic cases. As
Dr. Adams stated, the assignment of fracture
cases in a general hospital service has been a
matter of considerable concern to all of us. From
the very nature of the case, it is inconsistent to
expect that the general surgeon shall be equally
adept and interested in fracture work. The frac-
ture problem is becoming entirely different from
the straight surgical service. I think in many
hospitals it has been assigned to the orthopedic
service because it more closely fits into the work
than it does into the general surgeon’s work. Many
of the smaller hospitals throughout the country
have been unable in the past to support an ortho-
pedic service because there were not enough cases
of a straight orthopedic nature to warrant such a
service. The usual orthopedic deformities were
not in themselves large enough in number to en-
list the services of a man who did orthopedic work.
However, many of our smaller hospitals are today
adopting a wise policy by putting the fracture
service along with the orthopedic service, which
enables them to maintain an adequate staff for
this kind of work. I know in several of the hos-
pitals in which I do the fracture work, we fre-
quently have as many patients, particulai'ly on the
male ward, as the general surgeons do. We have
in 2 of these institutions now adopted the prin-
ciple which the doctor has suggested here of the
man who first starts the treatment of a fracture
case seeing that case through. I do not think
it is at all fair to turn it over at the end of 1
month or 3 months to another man, who possibly
entirely disagrees with the treatment the first man
started. I was impressed recently by a Fracture
Symposium, which I attended at one of the Ameri-
can College of Surgeons' meetings, to see how few
of the most prominent authorities agreed on the
methods of treatment of ordinary fracture cases.
I think this brings out just one point: It is im-
possible to standardize the type of treatment of
any given fracture. Frequently hospital superin-
tendents buy fracture equipment because it has
been advertised as the type used by some promi-
nent man, and then attempt to fit their cases to
it. This is never entirely satisfactory. Every man
has to use the type of treatment which in his
hands has proved most successful. We all know
that certain surgeons throughout the country
have brought out operative methods for treatment
of conditions which in their hands are successful,
but it is impossible always to teach those methods
to men of lesser experience and lesser surgical
skill, probably with equipment they do not know
how to use. I distinctly remember a position 1
held at the Post-Graduate Hospital in New York
where I taught operative orthopedics on the
cadaver. One of the instruments that we used
was the motor saw that Dr. Albee devised, and
the doctors who had come from all over the coun-
try to take a 6 weeks’ course were taught the use
of that motor saw. Some of the men used it well;
they were mechanical by nature. But I also re-
member the difficulty encountered by others.
I don’t believe we are ever going to be able to
standardize the treatment of fractures. A man
has to use that method which in his hands gives
the best results, providing he has been well trained
and takes the opportunity to acquaint himself with
the new ideas and new methods of men of repu-
tation. I don’t think it is ever fair for that reason
to turn a case, the treatment of which has been
started by one man, over to another before that
treatment has been finished.
In reference to Dr. Martin's remarks about in-
surance companies being willing to pay for good
treatment, I think there are 2 sides to it. I have
been told from time to time by some of the respon-
sible men in insurance companies: “Doctor, we
want good work. We are willing to pay for good
work, and if good work is rendered we will see
that you are amply compensated for it.” I be-
lieve this is the attitude of the better companies.
However, there are many claim agents who feel
they must “shop” in medicine as they would for
ordinary commodities and are still looking for
cheap treatment regardless of quality. I do work
for some companies that never question the bills;
they want good service and -seem to think we are
giving them good service, and are satisfied with
our bills. However, we are constantly receiving
letters from some companies requesting reductions
of bills, objecting to the charge which we have
made, when that charge is what we have adopted
as standard for the same type of treatment. My
experience has been that some companies, as Dr.
Toye brought out, still want cheap work. They do
not realize that they are paying a great deal more
in the end than they would be by hiring a man
who makes it his business to render better service,
even though at an increased initial cost. I believe
most companies, sooner or later, find out the men
who are competent, and are willing to pay them a
fair price for their services.
Dr. John F. Hagerty (Newark) : I think if any
argument were needed to prove the truth of what
10
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
Dr. Adams has said, it lias been supplied by the
pictures shown by Dr. Martin, that fractures or-
dinarily are not properly cared for.
In St. Michael’s Hospital until 7 years ago the
fractures were taken care of by the general sur-
geon, and, as has been well expressed here today,
the general surgeon has not the temperament for
taking care of fractures. Accustomed as he is to
dealing with acute illnesses and acute infections,
the general surgeon has not the temperament to
care for patients whose care lasts over a very
long time, nor has the average surgeon the me-
chanical skill required. I think it requires a
peculiar type of ability to care properly for frac-
tures, and that ordinarily is not possessed by the
general surgeon. We decided, therefore, in St.
Michael’s 7 years ago, to set up a special fracture
service, and there all of the fractures that are ad-
mitted to the hospital are admitted to the care of
one man, Dr. Fort, who has a group of assistants,
and who cares for them properly.
As has been well pointed out, in the old days
sometimes* a fracture would be admitted at the
close of the morning, after the surgeon had spent
an arduous period operating, and he would direct
somebody to see that the patient received tempor-
ary care and he would look after it later; whereas,
quoting from Dr. Martin, when a fracture is cared
for immediately it becomes a very simple thing
and easy to take care of.
Dr. Frank W. Pinneo (Newark) : Dr. Adams has
shown that fractures for treatment, form one,
distinct, group in medicine. That brings out 2
things; the fundamental principle of undivided re-
sponsibility, and yet, at the same time, the need of
cooperation. Now the fear that many doctors
have of fractures should not result in inadequate
care of the patient nor, on the other hand, in the
mistakes of the patient’s care shifting from one
to another service.
The demonstration that Dr. Martin has given
follows up Dr. Adams admirably, and some of his
remarks recall to mind what Sir Robert Jones
told us in the armies, that the orthopedist must
“work for function from the start”. This is con-
trary to the conception that all a patient needs at
First is treatment for his infection, and, after that,
he can be made over again, to improve, or save
from further, deformity, it being rather implied
that his fracture, or other injuries, must neces-
sarily involve some deformity, whereas proper
treatment from the start would prevent deformity.
As to the relation between industry and our pro-
fession, I do not see why there should be a dis-
agreement when both parties are aiming for the
same end-result. We must admit that frequently
the operation of the law is very faulty in substi-
tuting the interest of the insurance company for
the professional skill necessary.
Dr. William J. Arlitz (Hoboken) : I don't know
that I can add anything to what has already been
said. The remarks of the gentleman “that insur-
ance companies are not willing to pay” is, I think,
far-fetched. There are a number of men in the
room who are specializing, and whom I have
called upon on various occasions to offer their best
judgment and treatment in cases. The insurance
companies were always willing to pay for proper
services. They do want capable men to treat and
examine their cases.
In the Compensation Bureaus we see the end-
results of fractures that have been treated by the
ordinary surgeon and by the orthopedist. I do not
consider the orthopedist more capable than the
general surgeon. When 1 say “general surgeon”,
I mean a man who is a recognized visiting surgeon
at a good hospital and who is experienced. Such
surgeons usually get good results. Poor results
are those where the fractures are treated by men
who have had little surgical experience. They all
have a method of their own. Most of their
methods are not good; but in the final analysis,
the visiting surgeon at a hospital gets as good a
result as the orthopedist. They both get good
results.
I know that the railroad companies — and I rep-
resent quite a number of them — are always willing
to pay for good service. The insurance companies,
likewise, are always willing to pay for good ser-
vice. They do object to huge bills for the treat-
ment of minor injuries — large bills are not un-
usual.
We have been criticizing the results in trau-
matic surgery for a great many years. I don’t
think that our criticism has brought about any
great improvement in methods. I don’t know how
you are going to bring these about.
Dr. Martin was talking about the "aggravation
of a preexisting condition”, after trauma. The
majority of you would be amazed if you went into
a Compensation Bureau and heard these various
alleged accentuations. There are a number of men
here now, who have been associated with me in
the defense of such cases. A man will have a
small burn of the foot, and a troupe of doctors
will come in, and they will allege that this man
is now suffering with advanced tuberculosis as a
result of that burn of the foot. Another man will
have a troupe of doctors come in and say that
the man is suffering with a gastric ulcer as a
result of a contusion of the foot. They claim all
types of aggravations and accentuations after
minor injuries. I don’t know how you are going
to put a stop to it. I know many members of the
County Societies and members of the State So-
cieties, who make these allegations. It would not
be good judgment to say that all doctors who
make these allegations ,are liars, because some-
times trauma does produce aggravation of a pre-
existing condition. A frank expression of opinion
in many of these cases would not look good in
the record of the case. Aggravation is so fre-
quently claimed that I usually request that a
specialist examine such cases in consultation. The
specialist is. of course, one who has a special
knowledge of the particular allegation. These ag-
gravations are alleged year in and year out. I
have devoted many years to these problems, but I
am frank to say that with all of my experience I
am unable to offer any solution for these per-
plexing problems.
Dr. J. Bennett Morrison (Newark): At this time
I am going to ask you to recall the paper I read
to you on Wednesday morning — on industrial medi-
cine. I ask you to recall the plea that was made
for an extended cooperation between the medical
profession and the carriers in a effort to produce
better results, better after-results in the treatment
of the laborers in the state of New Jersey. I told
you that some of the carriers were anxious to
clean house and were coming to us begging for
our assistance to raise the standard of surgical
ability of the men who are treating those cases.
I told you that some of the carriers were willing
to pay your bills as rendered if it be proved that
you are reputable men; that they reserved to them-
selves only the privilege of referring bills which
they thought excessive to those committees in
the state of New Jersey which we have provided
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
11
to pass upon questionable bills; and I told you
that they stated that they always paid the bill
after our committee passed upon it. I can tell you
instances in the state of New Jersey where in-
surance companies have paid single bills up to
$1000 for surgical procedures, one bill of $1200.
TVe have taken this opportunity to bring to you
this morning the Medical Director of one of the
largest carriers in the United States. Bring him
upon the floor here, treat him as you would any
other speaker. Here is your opportunity to find
out about the relation of your work to the com-
pensation work. Let us ask him if the carriers
have an association where the better class of car-
riers can induce the poorer class of carriers to
try and elevate their work?
I am very glad indeed that the doctor showed us
that series of pictures. I have been practicing
medicine and surgery for the past 30 years. I do
not believe there is a man in this audience, be he
specialist or general practitioner, who ever had
the results that were shown to us this morning.
Those results are a condemnation of the class of
men that the carriers pay to take care of indus-
trial medicine. That is the class of work that is
a reflection of the very men who are discrediting
industrial medicine. That is the class of men who
do the cheap work that some of the carriers want
to get away from. Those pictures show in them-
selves that the carriers have paid on that series of
cases alone probably $100,000 more in prolonged
disability and total disability than they would have
paid had they employed the average competent
surgeon to take care of their work.
Here is an opportunity for the carriers to tell
us what class of work they want, ask our co-
operation in securing that better class of work,
and assure us that they are interested in it and
are going to pay for it when the time comes. We
all know that industrial medicine is here to stay.
We all know the type of men who are engaged
in it. We all know the better class surgeons
have been discouraged because of the number of
times they are called to court, because of the ques-
tion of their bills, and because of the unsatisfactory
relations between them and the carriers.
Now, for the next 100 years we must keep push-
ing our attempts to get a closer cooperation be-
tween the medical profession and the carriers.
There may be faults on both sides, but the
greater portion of the fault, as we can see it, is
from the carriers' side. Here is an opportunity
to question this man, and here is an opportunity
for him to lay his cards on the table and tell
us what he wants us to do in order to better this
condition.
Dr. Maurice S. Avidan (Newark) : I have been
associated with the State Department o'f Labor
for several years and, having had the opportunity
to review a large volume of this work, I should
like to present certain facts. In the first place,
the type of fracture and other industrial work
that is being done in this state at the present
time is far better than it has ever been before.
This includes the work from the general profession
at large. One reason why the work has made
such an improvement is because of the fact that
there has been created a very important depart-
ment relative to industry, which is a sort of clear-
ing house for all industrial work, called the Com-
pensation Bureau, through which medium a check-
up can be made of the character of work of each
man engaged in the practice of industrial surgery.
Each case of any importance must pass through
this Bureau and its functional end-results are
made a record and evaluated. This is done by
careful studying of each case from purely a medi-
cal and surgical standpoint, including clinical,
pathologic, x-ray findings and prognosis as to
function. Consultations and conferences in the
more serious cases have been of great value in
determining this factor. A public record is made
of each case.
I have always felt that the fracture work should
not be taken away from the general surgeon. I
have seen some very good results among the gen-
eral practitioners and have also seen some very
poor results among the industrial and bone spe-
cialists. I think that the general practitioner who
is conscientious and who knows his limitations is
very capable of handling this class of work. I
also think that some of our bone specialists are
at times a little over zealous and often too radical,
especially in the open operative field.
After all, industry demands good functional re-
sults with the least amount of lost time. Dr.
Martin demonstrated some very poor results in
fracture work. I do not think that is the type
of work that is found in New Jersey; and if some
of these poor results should be found, then indus-
try and the insurance carriers should have no
complaint, because they have full control of the
medical situation, as to choice of doctor in each
particular case. They have taken advantage of
that right under the Act and have been given
full sway in making their choice. Dr. Martin
stated that in his opinion there should be . no
question about the payment of medical bills if
the work is properly done. Dr. Martin represents
one of. the largest1 insurance companies in the
country and it is very gratifying to the medical
profession to know this. From my experience I
believe 90% of the insurance companies have co-
operated and have done fairly well, everything be-
ing taken into consideration. They frequently
come to the State Department for suggestions and
advice concerning special treatment. Therefore, I
don’t think that they ought to be unnecessarily
criticized. However, a few of the companies in
the last few years have tried to take advantage of
some of the doctors; but in the long run they
have not succeeded. Quite often the doctors have
had grounds for criticism, but in the large ma-
jority of instances it was due to misunderstanding.
One of the greatest problems we have to deal
with in this state, and one which cannot so easily
be solved, is the question of expert medical testi-
mony in compensation cases. As Dr. Martin
stated, one expert will state that a man has 10%
loss of function of a limb and another will state
he has 80% loss of function. In these instances
we are compelled to resort to courts and to have
laymen decide questions that are purely medical in
nature. It has become a serious problem because
it puts the medical profession on the defensive and
very often in a very embarrassing position. There
are members of the medical profession who make
a specialty and have no other form of prac-
tice than giving expert opinions on disabilities in
courts. There has been an attempt to overcome
part of this perplexing problem by urging medical
conferences and consultations; which in many in-
stances have proved successful, especially where
there was wide difference of. opinion.
Dr. Henry II. Kessler : I just want to add a
little note of optimism and sort of second the
statement just made by Dr. Avidan. About 10
years ago we used to see those same results which
you saw on the screen a fe’jv moments ago; but
fortunately we do not see them now. I am quite
12
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
sure there has been a marked improvement in the
end-results of the treatment of fractures, both by
the orthopedist and by the general surgeon. How-
ever, I do think we should aim toward a definite
goal regarding the general relationship between
the cax-riers, industry and the medical profession.
I feel there has always been a spirit of conciliation
between the various groups. Today, at least in the
northern part of this state, we do not see indus-
trial surgery or traumatic surgery in the hands
of a very few. There has been a tendency on the
part of carriers and industry as a whole to dis-
tribute the work rather evenly among the general
practitioners and surgeons.
As a general rule, the bills that come from com-
petent men, men who are on the surgical staffs
of recognized hospitals, are rarely questioned.
Then, of course, we have a different set-up, of
which I will tell you this afternoon which helps
in the adjustment of medical differences.
I would like to see a special fracture service
in hospitals. I am in accord with the previous
speakers on the subject. At the same time there
is still room and still an opportunity for the gen-
eral surgeon who is interested in fracture work
to get aboard the bandwagon. No better instance
can be pointed out than the fracture service at the
Massachusetts General Hospital. There you see
orthopedic surgeons and general surgeons co-
operating in performing some of the finest frac-
ture work in the country.
Dr. J. K. Adams: First, Mr. President, I did not
mean to state — I don’t think I did state — that I
wished any differentiation whatever in the treat-
ment of fractures by general surgeons or by or-
thopedists. If Dr. Arlitz understood me to say
that, if he thought I said the fracture services
were not properly handled by general surgeons,
he is mistaken. What I stated was that there
should be a fracture service established, that is,
that the rotating- type of service should be abol-
ished. Yrou could call it a “traumatic service”,
or a “fracture service”, or you could call it any
kind of service you wanted to; but I have made no
•differentiation whatever between general surgeons
and orthopedists. I even went further, I said let
anybody treat the fractures who wants to treat
them, but make someone responsible.
When Dr. Hitchcock presented his paper on this
subject, which was the most illuminating I have
ever heard or expect ever to hear, he distinctly
ended his argument by stating that if he had a
severe, compound, infected fracture of the femur,
or any other long bone, he would rather be treated
by a good, earnest conscientious man who under-
stood the principles of what he was doing than by
the 3 greatest stars who ever lived; and what he
was referring to was the rotating- service. That
is my point. In this fracture business we go
through fads. We do things because it is the
style. You will remember that about 20 years
ago we were going along in the same old routine
way when Arbuthnot Lane, of England, made a
visit to America. He was the master of a per-
fectly extraordinary technic in the application of
medical plates to bones; the result of years and
years of extensive study and splendid concentra-
tion: a technic that was impossible for the aver-
age man ever to approach. Within 6 weeks after
he arrived, the steel mills were busy turning out
plates to put on broken bones; and some of the
results were perfectly frightful. Not only were
these plates put on patients who did not in any
sense require them, and who could have been
treated by a closed method perfectly well, but it
was the style to use steel plates — and the Lord
knows they were used in America, there is no
question about that.
Now, as to what Dr. Toye said about the general
surgeon being unwilling to wait, or not being
trained to wait, and what he said about the or-
thopedist being more or less trained to wait is,
I think, true in a certain sense. The orthopedist
has naturally been forced into a waiting attitude
as the result of a great deal of bone pathology that
has come under his attention, such as tuberculous
spines, and tendon transplantations followed by
long periods of muscular education. I think that
is true. It is natural for a man who has been
brought up to play cricket in England to spend
3 days playing a game; while in America we want
to see a ball game in an hour and a half. We are
not accustomed to have a man go to the bat and
take 3, 4 or 5 hours to make 150 runs; we expect
him to do something right away, either strike out
or get on first base.
In regard to this insurance company proposition:
we all have had our experiences from which to
form our opinions. Naturally, the opinion we
have is the result of our experiences. If you
have sent 150 bills to insurance companies in a
certain length of time, and every insurance com-
pany has sat down and sent you a check promptly,
you do not feel that there is anything to com-
plain about.; but when a great many insurance
companies on a great many different occasions
refuse to pay your bills, why then you don’t feel
that insurance companies have exactly rushed for-
ward with money. That is the point.
I have had some of those experiences, I must
admit. I even had an instance where an insur-
ance company wrote me that my bill was too low,
and sent me a check for a higher figure. But
that was only one instance! (Laughter.) I think
1 sent them a bill for $25, and they thought the
result was very nice indeed, and that I had under-
charged, and sent me a check for $50; but that
isn’t a daily occurrence. That is what I want to
bring out.
Now, these are exact facts, and there are men
here who can back me up on them. My experience
has been somewhat like the experience of Dr.
Toye. A man was struck on the back by a heavy
hoist that was lifting a large stone. He was com-
pletely paralyzed below the waist. He was brought
into the hospital. A careful examination was made
and it was found that he was totally paralyzed be-
low the point of fracture, which roughly was
somewhere around the first lumbar vertebra. He
had absolutely no control of the bladder and no
rectal control ; no sensation whatever below the
waist. He was in very decided pain. I was asked
to see him by the physician for the company for
which this man had worked. He told me that he
wanted me to see the man, and he wanted me to
suggest a treatment to have carried out, that he
would be prepared to assist in carrying it out,
and if he was not able to do it alone would get
some one to assist him, and that he had au-
thority from his company to ask me to see the
man. I saw the man. We made the examinations,
we x-rayed him, and found he had a fractured
spine, naturally. It was not quite so bad as we
had thought. This man was put up with a head
apparatus with traction on it, and -with traction
on his feet also. He did not do well. I saw the
representative of the company, who was an ex-
ecutive of that company, in that hospital with a
great many of this man’s relatives and friends
within a few days, and they wanted to know what
I thought about his condition, and I told them
very plainly that I thought the man was very
Jan., 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
13
seriously injured, that I did not think that he
would ever walk again, and I questioned whether
he would live. Well, that was discouraging, of
course. Now, this accident, while I will not say
that it was absolutely the fault of this company,
I know that the company felt that it was a
little to blame because the representative told me
so, or intimated that it had not taken the safe-
guards that it should have taken to prevent that
accident. The representative asked me if I would
mind having someone else see this man in con-
sultation with me. I said: “Certainly not. Have
you anybody in mind? You can have anybody
that you want see this man, anybody that you
think can be of service or of the slightest assist-
ance.” In the course of the conversation the name
of Dr. Albee, of New York, was suggested as a
proper person to come and see this man in re-
gard to what the probable outcome of the case
would be and as to what the treatment should
be, the subsequent treatment. Dr. Albee said he
would be very glad to come, and he did. Fie made
a very thorough and careful examination of the
man, and said he had nothing whatever to sug-
gest in regard to the future treatment. He said
he would come again in 6 weeks and see the man
and ascertain whether he was doing well, and
that the advisability of what should be done would,
of couse, depend on what the examination revealed
at that time. Now, I saw this man 5 or 6 times,
went a considerable distance from where I live to
see him, and he was being taken care of daily by
the physician of this company and another physi-
cian had been called in to assist him. He had
a number of radiographs, and his board was being
paid in the hospital by this company. At the end
of about 3 weeks the man died, and the physician
who treated this man sent in his bill. It was a
larger bill than mine, very much. It was paid.
The other physician who assisted him sent in his
bill. That was paid. The x-rays were paid for.
The hospital was paid. Dr. Albee was said to
have been paid, and I think he was; at least this
man said so. I sent this representative a bill for
$100. As I said, the patient was seen by me 5
or 6 times, and I went an appreciable distance
to see him. I did see other cases when I was there
on most occasions, but on 1 or 2 occasions I went
up there just to see him. I got a letter back
from the insurance company saying: “We don’t
see why we should pay your bill. We would like
you to write a letter in explanation of your bill
and send it to the State Department of Labor
and explain why you have sent us this bill.” The
executive of this company who saw this patient
with me, and who saw him in the presence of his
relatives, stated in the presence of these relatives
that there was no expense whatever that this
company would not pay to put the patient on his
feet again if it was humanly possible. I wrote
Dr. Avidan a letter about this matter and asked
him what to do about it. He replied that he would
be very glad to take it up, that he would write to
the insurance company, but he said, “We have no
authority to make them pay, but I will be very
glad to write a letter for you and see what can
be done in the matter”. Flave they paid? No, they
have not, and I don’t suppose they ever will un-
less I sue them. Now, when you tell me that in-
surance companies are always glad to pay, do
you wonder why I disagree with you?
Dr. J. W. Martin : I did not know I was going
to get into a commercial argument here today.
I am not going to hold any brief for insurance
companies. Up until a year ago I had the pleas-
ure of being a doctor myself. It is true that in-
surance companies do have claim departments
which try to get you down to the last cent. I did
this work until a year ago, and I was tremen-
dously interested in traumatic surgery. I will have
to tell a little about myself. I know how the
medical men do not get together as a unit, but act
as individuals, and the one fellow fights the other,
and how the Claim Departments, if they can, will
whip you down a dollar. So, when I went into
this Department, I said, “We are not going to
have any fee schedule, and the Medical Depart-
ment is going to run as a separate unit, not con-
nected with the organization”. And that is true
as far as this company is concerned, and that is
all I am interested in.
If men will charge a reasonable fee, or charge
the insurance companies what they would charge
in that case were it a private patient, insurance
companies would pay for it, and they would pay
for it without any trouble, and they would pay a
whole lot more than would a private individual
because a private individual could not afford to
pay the economic value that the insurance com-
pany could. They are dealing in dollars and cents;
but it so happens if they deal in dollars and cents,
we are dealing with the human side of it, and the
two go hand in hand, as I tried to bring out in
my paper.
Now, these end-results — they were not from New
Jersey, but they were from different states in the
Union. I do not think, Gentlemen, from looking
over the files and records in the United States,
we are doing good work. It is not because we do
not know better; we are indifferent to it.
It is up to you to get behind this thing and say
to the insurance companies: “We are going to give
you the best there is, and you are going to pay
for it.”
Dr. Weigel (Plainfield) : May I ask Dr. Martin
just one question? He has said in his rebuttal, as
it were, that if the doctors would charge the in-
surance company for the treatment of cases what
they would charge ordinarily to individuals if the
individual was to pay the bill himself, the insur-
ance company would very gladly pay that much
or possibly more. Now, it is my understanding
of the average compensation law that it was put
into effect for the very reason of giving that man
some compensation and paying for his treatment
because he was injured while in the employ of
whoever happened to have hired him. I think
everyone of us feel that if these men were in-
jured When not working for the company employ-
ing them, they would all be charity patients on
the ward service. Invariably, these laborers are
the heads of large families, who can’t pay a sin-
gle thing for their treatment. The same man if
he is injured after his work on his way home, for
instance, by an automobile, pays the doctor ab-
solutely nothing for his services; and it seems to
me that if the insurance companies are going to
tell us that we should charge for these services
just as we would charge him as a private indi-
vidual, we would have to treat every case for
nothing.
Dr. J. W. Martin : I don’t know how to make
myself clear, but I don’t see how I can make it
any plainer than this: What is going to be the
ordinary charge for a broken femur for a man
who is working at $4.50 per day; and, we will say,
who has a family to support? You say he goes
into the ward and you don’t get anything. Well,
I imagine that $150 or $200 would be a good price
under those circumstances.
14
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
•Ian., 1931
Ur. Weigel (Plainfield) : Yres, but the man could
not pay that.
Ur. ■] . W. Martin : But the insurance company
would pay you.
Now, as far as the compensation law is con-
cerned, I tried to bring out in my remarks that
I would welcome the day when a universal com-
pensation law was adopted. Down in some of the
Southern States, for instance, a man has a broken
leg. The compensation law says $100. Well, how
long does that last? As long as a snowball in
some place. The fellow has still the fractured leg,
and it must be taken care of. Industry must be
philanthropic, because if they let that leg go im-
properly cared for. then they are going to have
a tremendous amount of disability; therefore, they
cannot recognize your compensation law, they
have to pay several hundreds of dollars for the
care of the case, and willingly do it because if
they get a good result it is cheaper for them.
However, our troubles are we don’t know what
charges we are to make. 1 think that is the
trouble. One of us might think that our time is
worth a whole lot of money. Well, if it is, then
don't fool around with this sort of work; but if
you can take it in along with your practice in a
general way, and get a general fee for it, all well
and good.
I will say frankly, from a commercial stand-
point, for every dollar that this company takes in
— and I believe it is the same way with all com-
panies— they are spending $1.50, so they are not
making any money on it. My Department alone
spent $2,000,000 to the medical profession of the
United States, anu, therefore, I believe that the
insurance companies are giving a little money to
the profession.
Fig. 1.
Chairman McBride : We have had a very splen-
did morning. These papers have all been very
worth wrhile, and I want to thank at this time
the speakers who presented them, also the discus-
sants. It has been very illuminating, and I be-
lieve we have gained knowledge by their presenta-
tion and discussion.
GASTRO-INTESTINAL DISORDERS IN
RELATION TO DEFECTIVE
GASTRO-INTESTINAL
MECHANICS*
Charles Gilmore Kerley, M.D.,
New York City
That gastro-intestinal disorders of widely
varying types may be occasioned by faulty
structural gastro-intestinal relations in the
adult has been known for years. It has been
known that displacements, dilatations, angu-
lations and peritoneal bands have a pro-
nounced effect upon function; that similar
* (Lantern Demonstration at the lG4th Annual
Meeting of the Medical Society of New Jersey, Sec-
tion on Pediatrics, Atlantic City. June 14, 1930.)
1. Iliac Crest.
2. Stomach erect lower margin.
3. Transverse colon erect lower margin.
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
15
conditions might exist in a child has received
but scant attention.
The child is given the credit, without investi-
gation, of being structurally normal except in
such strikingly apparent conditions as pyloric
disturbed physiologic function in which the
matter of food and chemistry is emphasized.
Further, the young child, because of lack of
development, is prone to nerve imbalance — a
systemic failure of coordination. This ap-
Fig. 2 -A.
stenosis, imperforate anus or other gross
anomalies. It has been, and is, largely the
medical habit to attribute all types of gastro-
intestinal disorder in infants and children,
from vomiting to constipation, primarily to
plies particularly to that part of the baby
which comprises the gastro-intestinal tract,
where function is entirely under the control
of nerve impulses. Imbalance and incoordi-
nation of the independent parts of the gastro-
JOURNAL OF THE MEDICAL SOCIETY OF NEW JH RSEY
Jan., 1931
] G
intestinal mechanism explain many of the
functional gastro-intestinal disorders of early
life.
During the past 20 years I have in different
contributions called attention to the depen-
dence of many gastro-intestinal ailments in
children on defective gastro-intestinal mechan-
ics. The nature and some of the results of a
loss of appetite in the infant or young child?
The answer — presence of food in the stomach;
food retention beyond the time when it should
have passed into the intestine. Hunger pains do
not occur in a partially filled stomach. I have
investigated a vast number of these loss of ap-
petite cases through giving a test normal
breakfast, consisting of milk, cereal, perhaps
Fig:. 2-B.
poorly functionating gastro-intestinal ma-
chine comprise the aim of this contribution.
General practitioners and pediatrists are con-
sulted daily by parents concerning children
in whom the chief complaint is habitual loss
of appetite ; often with associated symptoms
of eructations of gas, stomach pain and, in
many, habitual vomiting.
What is the outstanding cause of habitual
an egg or bacon and a breadstuff, and then by
means of a stomach tube determined the pres-
ence or absence of retained food, 4 hours or
more after completion of the meal — repeat-
edly finding food residue 5-6 hours after the
meal.
Fig. 1 demonstrates a girl, Sl/2 years of
age, who had persistent loss of appetite
with food retention 5 hours or longer after
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
17
a meal. In nearly all of such children there
is a mucous gastritis which can be demon-
strated by the thick mucus removed from the
stomach — shown in the illustration suspended
on wood applicators. This child’s food re-
Fig. 3.
tention after 5 hours varied from 1-3 oz. I
feel that the retention is caused by pyloric
spasm, due largely to gastric hyperacidity,
i Hyperacidity of the gastric contents in chil-
Fig. 4.
clren — Jour. A. M. A. Nov. 25, 1922 — by
Kerley and Lorenze.)
The thick mucus possibly acts as a plug
to the pyloric opening of the stomach. The
management in a case of this sort is re-
peated stomach lavage at least 5 hr. after eat-
ing. An ordinary 3 meal a day diet is allowed,
with the exclusion of fat and bananas; these
substances are invariably a part of the reten-
tion if given to children in whom this feature
is prominent.
Fig. 5.
In Fig. 2 is shown a girl, 11 yr. of age, who
came to us because of a persistently poor ap-
petite and habitual constipation ; eructations
Fig. 6 -A.
of gas and food were of daily occur-
rence and vomiting was fairly frequent. The
relative positions of the stomach and colon in
the erect posture are shown. The lower bor-
18
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
der of the stomach in a child of this age
should be 1 in. above the umbilicus. The
ptosed stomach is mechanically inefficient, a
slow working organ. Cases of this type also
show high stomach acidity and usually
mucous gastritis.
In Fig. 2-A, the position of the stomach
is indicated, according to the x-ray findings.
The constipation can in this instance be ac-
counted for by the ptosis of transverse and
descending colon and sigmoid ; demonstrated
in Fig. 2-B.
Management. The first step in treatment of
a case of this sort is to prevent a stomach
over-load ; but small amounts of fluid can be
given with a meal, and after a meal the child
should remain recumbent for 2 hours. Water
Fig. G-B.
is given sparingly, and not over a pint of milk
is allowed in 24 hours. Soups are excluded
from the diet. A powder composed of atropin
sulphate gr. 1/300, magnesium carbonate gr.
1. bismuth sub. carb. and sodium bicarb,
each gr. 2. is given 10 minutes before meals.
Parents are instructed to avoid condiments,
cold drinks and iced foods. A 5 hr. interval
feeding plan is invariably followed, with no
food between meals. Cases of ptosis in-
variably make a more rapid recovery if a
belt (Fig. 9) is worn during the time the pa-
tient is up and about. For the constipation a
dessertspoonful of mineral oil is given at
bedtime and aromatic fluid extract of cascara
Yz teaspoonful after each meal.
Fig. 3. Chronic appendicitis may also in-
fluence stomach emptying. In these cases we
find food retention, lack of appetite, recur-
rent vomiting, periodic pain and frequently
malnutrition ; constipation alternating with
diarrhea is frequently present. The illustra-
tion demonstrates bismuth in the appendix
96 hr. after the bismuth meal. The appendix
in this patient was removed a few weeks
after the x-ray study and was found badly
diseased.
Recurrent vomiting is frequently due prim-
arily to defective mechanics. A boy, 4 yr.
of age, came to us because of repeated
vomiting attacks which had occurred about
every 3 months for a period of 2 years. The
Fig. 7.
attacks were very severe, producing much loss
in weight and dehydration to the degree of
necessitating glucose solution intravenously
and subcutaneously. In Fig. 4 is shown the
spastic colon of this patient 72 hr. after the
bismuth meal; the bismuth meal being held for
this period of time by the spastic colon. The
child suffered from obstinate constipation, and
daily enemas were required in addition to co-
pious doses of mineral oil. This child repre-
sents the extremely neurotic type of individual,
manifested in the intestinal tract by exagger-
ated nerve impulses associated with imbalance
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
19
and incoordination. In this patient, under diet
and hygienic measures, atropin to the point of
physiologic effect, together with mineral oil
and the aromatic fluid extract of cascara ad-
ministered 3 times a day in doses of ^ dram,
relief of constipation and recurrent vomiting-
seizures was effected. Intestinal stasis of this
type invariably produces food retention in the
stomach beyond the 5 hr. period.
Fig. 5 demonstrates the stomach of a boy,
6 yr. of age, who suffered from violent stom-
ach colic. The illustration shows the stomach
in active hyperstalsis with spasm at both the
Fig. 8.
pyloric and the cardiac orifices. Because of
the double spasm, particularly at the cardiac
end, the child could not secure relief' by
vomiting. Localized circular fiber spasm may
occur at any point between, and including,
the esophagus and anal sphincter.
Fig. 6 A-B. This patient was an infant, 3
months of age, of the spasmophilic type who
was brought because of severe colic. The illus-
tration A shows marked muscle incoordina-
tion and circular fiber spasm. Illustration B
demonstrates complete coordination both
longitudinal and circular fibers in violent action
with immediate forcible evacuation. Nerve
imbalance and defective coordination of the
independent parts of the gastro- intestinal
mechanism explain the colic in this case, and
colic in general in infants and children. An
important point to remember is that pain ( col-
ic) due to nerve imbalance and muscle inco-
ordination is apt to be much more severe than
pain due to pathologic states — more tempor-
ary in character, and is further indicated by
acute paroxysms of pain and sudden relief.
In our radiographic studies we have demon-
strated 2 types of colic — stomach colic and
that of intestinal origin. There may be var-
ious remote causes but the immediate cause
Fig. 9.
ot the pain is the formation of gas block due to
muscle cramp, localized circular fiber spasm
with hyperstalsis of the blocked gut areas.
This infant had been carefully fed and no
change was made in the food formula. Atro-
pin. 1/1000 gr., was given immediately before
each feeding ; with an immediate cessation of
the colic. Ordinarily, these colicky infants re-
quire food adjustment, stomach lavage and
often-times dilatation of the anal sphincter.
Constipation and delayed bowel evacuation
can be readily understood by study of the
constipation group which follows: ,
Fig. 7 represents what may be looked upon
as a normal colon in a child 2 yr. of age.
20
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
Fig. 8 compared with Fig. 7 demonstrates
at once the cause of the obstinate constipa-
tion from which this child suffered. In cases
of this sort, evacuations are invariably de-
layed. An elongated redundant colon ex-
plains the delayed evacuation in the great ma-
jority of children studied by means of x-rays.
Any factor that causes delay in emptying of
the colon is very apt to postpone the emptying
time of the stomach, with consequent loss of
appetite. The management of cases of this
type comprises the use of the abdominal belt,
mineral oil, aromatic fluid extract cascara in
sufficient dosage, usually jA dram or more 3
times daily after meals, to produce 1 or 2 free
evacuations daily. X-ray studies of ptosis cases
demonstrates that a decided support is sup-
plied to the gastro- intestinal structure by the
use of the abdominal belt (Fig. IX).
In about 75% of the gastro-intestinal dis-
orders of infants and children are found due
to defective gastro-intestinal mechanism. There-
fore, every patient with a gastro-intestinal
disorder, with a history of chronicity, who re-
sists the usual common sense dietetic manage-
ment and properly directed medical measures,
is given the advantage of a complete gas-
tro-intestinal study by means of radiography.
Discussion
Dr. Percival Nicholson (Philadelphia) : I have
been interested in this subject for many years.
Dr. Kerley brought out some very important points.
One was in regard to chronic appendicitis, which
was very interesting. I have seen in the last 18
months about 7 cases of appendicitis that only
showed spasticity of the colon. They all showed
very definite and distinct changes in the appendix.
Some had adhesions with complete obstruction at
the end, and the children had a very uneventful
convalescence. I should like to ask if he has
taken any blood calcium analysis in the spastic
types to determine whether these patients had any
low blood calcium, with regard to administration of
calcium as a means of lessening spasticity.
Dr. F. I. Krauss (Chatham) : I feel that a pupil
requires a great deal of temerity to discuss the
paper of his teacher. Some thoughts occurred to
me as Dr. Kerley was reading this paper and show-
ing his radiographs, and I wish to ask him for
further discussion. First of all, the question of
loss of appetite in children, or poor appetite, which
usually begins after they are 1 yr. of age, is due
to 2 factors: first, the physical factor which Dr.
Kerley has portrayed, and secondly a mental one,
the influence of the mother on the child, that is,
her influence in trying to force too much and too
frequent feedings. We are hearing so much to-
day of mental hygiene that we must be careful
not to lay too much emphasis on this mental
side, but must remember the physical side which
is also very important.
I believe that many cases of poor appetite are
due to the frequent feeding of infants, especially
with sweet milk. I have noticed in keeping chil-
dren on lactic acid and lemon juice milk for the
first year that, when put on sweet milk, they
very frequently begin to lose appetite or to
have such symptoms as the doctor has spoken of.
In several of these cases I have gone back to
lactic acid or lemon juice milk and have kept it
up even during the second year, with relief of
symptoms.
The second cause is rickets and the loss of
muscular tone, particularly the lordosis due to
rickets in the first year.
A third cause might be due to the general ptosis
because of the upright posture assumed. There
is a tendency to forget that the child must rest
after meals. It leaves the table and runs about,
and immediately there is a drag and weight on
the stomach and intestines to which it was not
formerly accustomed. I have found that having
these children rest after each meal is a very im-
portant factor in correcting the conditions.
Dr. Kerley has brought out that these cases are
due to too much sweet milk in the second year
of life. We cannot go back to acid milk until we
have relieved the fermentative condition if it is at
all severe.
In treating cyclic vomiting I thought at one
time that it was due to too much fat and my
routine was to put them on skimmed milk, take
away butter, etc. I found a certain proportion
of these children went on with their attacks. I
had not taken into account the fact that these
children had ptosis, and had a great deal of heavy
mucus in the stomach; it was often more im-
portant than the amount of fat that was being
consumed.
Another point is that pylorospasm does not stop
in infancy. We think of it as occurring in the
first 6 months of life, but, as the doctor has
brought out, many of these children up to 6 and
7 years of age have a tendency to pylorospasm.
If we treat them as we do in infancy there is re-
lief. My greatest friend in the practice of medi-
cine for children is atropin. I have it made up
in tablets of 1-.1000 gr. and dispense it rather than
send a prescription to the druggist because I do
not know where the druggist buys his atropin.
and so many times if prescribed in solution it is
kept too long and has deteriorated; I make a prac-
tice to give it at the office as long as I want the
child to have it.
We should take more radiographs. It is remark-
able how few x-ray pictures of the gastro-intes-
tinal tract are taken; and it is not a difficult thing.
They bring out just these points that Dr. Kerley
has mentioned and I feel as he does that if we
do not do this we are practicing the medicine of
30 years ago.
Dr. Charles G. Kerley (closing) : It is quite im-
possible in a contribution of this kind to go greatly
into detail. My time allowance only permitted of
referring to essential points. Retention of food in
the stomach may be due to causes relating imme-
diately to the stomach, such as spasm at the
pylorus, mucous plugs and malposition, and to re-
mote influences such as delayed emptying of the
intestine or inflammatory conditions in any part
of the intestinal structure. The most frequent
remote cause is constipation, regardless of whether
it is due to the spastic gut, to ptosis, elongations
or angulations of the descending colon and sig-
moid. An important feature, therefore, in reten-
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
21
tion cases is free bowel evacuation. I see to it
that 2 evacuations occur daily, when bowel in-
activity is the apparent cause of loss of appetite
due to stomach retention.
Among- the food substances that are slow in
leaving the stomach, fats of all sorts and ba-
nanas stand out prominently. Atropin is of great
value in all cases of gastro- intestinal spasm re-
gardless of the location. It must be used in full
dosage, to the point of physiologic effect often-
times.
Probably three-fourths of the digestive ailments
of infants and young children are due primarily
or remotely to defective gastro-intestinal me-
chanics.
This applies equally to the acute as well as
habitual derangements.
CHANGES IN HUMAN RICKETS AFTER
VIOSTEROL THERAPY*
John Caffey, M.D.,
New York City
Fourteen cases of severe and moderately
severe rickets were studied clinically, chemi-
cally and roentgenologically, before and after
administration of viosterol therapy. The be-
havior of these rachitic patients varied con-
siderably and the group studied is not large
enough to warrant general conclusions, but 16
lantern slides were shown depicting the
changes after viosterol in individual cases.
One or more examples of the following types
of reaction to viosterol were demonstrated in
each picture.
(1) Appearance of the “line test” for
healed rickets, in x-ray films, after 14 to 21
days in the usual care of rickets on adequate
viosterol dosage (20-30 minims daily).
(2) The increase of lowered serum phos-
phorus concentration to normal after 7-14
days of viosterol therapy in the usual care on
adequate dosage.
(3) In high calcium rickets, a depression
of the abnormally increased calcium to normal
concentration before increase in the depressed
phosphorus concentration began.
(4) Rapid increase in the lowered calcium
concentration, and rapid disappearance of clin-
ical symptoms of rachitic spasmophilia, after
adequate viosterol dosage. Calcium concentra-
*(Read at the 164th Annual Meeting of the Medi-
cal Society of New Jersey, Section on Pediatrics,
Atlantic City, June 14, 1930.)
tion became normal after 48 hr. Laryngo-
spasm in 1 case disappeared after 24 hr., and
Chvostek’s sign subsided after approximately
96 hr. in a second case.
(5) Persistence of craniotabes for 30-40
days after adequate viosterol therapy and
many days (10-20) after the “line test” for
healing had become positive in x-ray films
of the long bones, and after serum phosphorus-
concentration had increased to normal and
the product of the calcium plus the phosphorus
exceeded 40.
(6) Marked clinical improvement occur-
red in all cases which showed chemical and
roentgenologic healing after viosterol. The
clinical improvement was manifested chiefly
by increased activity and gain in muscle
power, improved disposition and appetite, and
gain in weight. None of the patients was
definitely anemic, nor did any of them show
enlarged spleens previous to viosterol therapy.
(7) A few patients treated with inade-
quate amounts of viosterol (5-10 minims
daily) showed a greatly retarded response to
viosterol and 1 showed no signs of healing
after 40 days.
(8) The results with viosterol in this
group of rachitic infants approximate those
previously reported with cod-liver oil and
ultraviolet light therapy.
Discussion
Dr. Stafford McLean (New York) : I quite agree
with Dr. Caffey’s statement regarding the favor-
able effects of viosterol therapy in rickets as
shown by x-rays. It is a helpful piece of academic
work.
That rickets is a very important disease needs
no argument and any accurate observations on
the results of new therapy are of value to all of
us. Dr. Caffey has asked me to show some x-ray
pictures of healing with cod-liver oil, for in spite
of the favorable changes in chemistry, and healing
as shown by the x-ray with viosterol, we are both
very cautious When teaching medical students
about the use of viosterol. YVe stress that suffi-
cient evidence has thus far not been obtained re-
garding indications for the use of viosterol except
possibly in certain types of cases, and that for
general use either for prevention or cure it is not
a substitute for cod-liver oil.
It was formerly thought that rickets was present
only at certain age period. I have a radiograph in
m'y possession of an infant taken on the first day
of life by Dr. Maxwell of Pekin. The mother had
osteomalacia and this infant showed definite x-ray
evidence of rickets at birth. This child was
cured roentgenologically by giving the mother, who
was nursing the infant, viosterol. At the end of
a month there was marked evidence of healing.
We have seen x-ray evidence of rickets at 6 weeks
22
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
of age in New York, and I have seen autopsies on
infants 2 months of age who showed microscopic
evidence of rickets. Rickets in our experience
may occur in the second and third and fourth and
oven fifth year of life but in decreasing frequency.
(Slides shown.)
Dr. Blanchard : Do you feel as the result of your
observation that it is better to give some cod-
liver oil routinely with viosterol?
Dr. Oaffey: Yes, I think it is better to give cod-
liver oil with viosterol. If you want another sub-
stitute for the vitamin A content, egg yolk con-
tains vitamin A in high concentration. We have
given viosterol in large dosage with no signs of
lack of appetite. Large dosage in our experience
does not seem to have any untoward effect.
SOME ODDITIES IN ACUTE MASTOID
DISEASE*
W. L. Pannell, M.D.,
East Orange, N. J.
To a body of men so widely experienced in
clinical and operative otology, it is scarcely
possible to introduce a single oddity that has
not previously been met. Nevertheless, this
Section might care to consider, by way of
diversion, any little oddities incident to aural
practice, and which go to make up the larger
horizon for the otologist. Dwelling on the
peculiarities of a disease, however, a grave
danger lurks in the possible habit of missing
the bigger issue. It is on this score that we
feel some reluctance in appearing to capitalize
items of important but often of wayside in-
terest.
Perusal of literature on the atypical reveals
interesting points of view, and one could not
do better than quote the words of 3 recog-
nized workers in our specialty : Benjamin
Schuster, discussing Ersner’s paper on aty-
pical mastoiditis, stated that were he to write
a book on otology he would endeavor to teach
the student even more about the atypical
than the typical mastoid. The late S. Macuen
Smith, in a paper read before the Southern
Medical Association, emphasized the tragedy
resulting from unrecognized or atypical forms
of mastoid disease. Frank Allport, being
♦(Read at the 164th Annual Meeting of the Medi-
cal Society of New Jersey, Section on Ophthal-
mology, and Otorhinolaryngology, Atlantic City,
•Tune 13, 1930.)
asked to discuss T. H. Harris’ paper on aty-
pical mastoiditis, demurred somewhat on the
ground that he had met so many atypical
cases that it had become hard for him to
know what constituted the typical.
Apparently, we are brought up on the ortho-
dox mastoiditis of text-book writers, only to
be asked to bolt to some extent time-honored
points of diagnosis. A friend practicing
otology said that in his intern days all was
definite and clear to him, whereas after 20
years of experience in a busy clinic he had
learned that practice was a great amender of
early ideas. The mastoid appears to intrigue
one with the simplicity of its signs of disorder.
As time goes on, however, the student is
slowly but surely undeceived.
The first recorded mastoid operation was
performed in 1740; Jean Louis Petit, a gen-
eral bone surgeon, having that distinction.
Nearly 100 years elapsed before any treatise
on otology appeared — that by Itard — and
peculiarly enough, the first clear description
of mastoiditis did not appear for 2 more gen-
erations, waiting on Friedrich Bezold to chart
the signs of that disease. After nearly 200
years of mastoid surgery it is noteworthy that
there is still discussion as to the relative value
of symptoms calling for surgical intervention.
Of the many odd things that are informally
talked about by our associates in an ear clinic,
it is a jolt to me to discover that a thing that
is important enough to make conversation be-
tween friends falls far short of the require-
ment for such an occasion as this. To sift
out the experiences that might be of most
interest to you is indeed difficult, and pre-
sumes your indulgence. Mackenzie has hinted
that unusual anatomy may be responsible for
atypical disease, while G. E. Roberts states
that strange anatomy is sometimes baffling to
the surgeon. Accordingly, it may not be amiss
to consider for a moment the anatomic side
of acute mastoiditis.
Of the structures in close relation to the
operative area, the facial nerve may, by a rare
chance, prove of importance both symptom-
atically and surgically. Alderton, in his series
of specimens, found that the facial canal
varied in depth from the suprameatal spine
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
23
11-20 mm. Likewise, variation of nerve posi-
tion in the region of the oval window was
marked, considering the small size of the sul-
cus through which it passes. Toward the
stylomastoid foramen the path may vary suffi-
ciently from the normal to invite trouble, es-
pecially if the surgeon follows the sigmoid too
far toward the jugular bulb. Byrd speaks of
noticing the facial in an anomalous position
while making the primary groove in a simple
mastoid operation. A study of the bony canal
in Alderton’s opinion does not reveal de-
hiscences in many instances. Early palsy in
acute otitis media may come from the sur-
rounding cells or through a breach in the canal
itself ; the latter statement is disputed by
Politzer.
A boy aged 16 came to the clinic with a
strange facial expression, voluble type of
speech, and history of double acute mas-
toiditis 6 months previously. Double facial
palsy comes under one’s notice rarely, and
reference to this case may .be appropriate
under the title of odd things that may be met.
On the anatomic side of our oddities by
far the most interesting seem to relate to the
lateral sinus. Seymour Oppenheimer gave
some interesting data on this venous channel
in connection with his research, on the venous
system of the temporal bone. He cited an in-
stance where the emissary vein was quite as
large as the lateral sinus. This recalls the dis-
secting room experience of J. C. Beck; find-
ing 2 sinuses on the same side. Allison T.
Wanamaker, in his recent article on sinus
thrombosis before the “Triological” society,
incidentally mentioned that the right sinus was
usually larger than the left and more sus-
ceptible to involvement. While the position
of the sinus is a problem in chronic mastoid
disease it may also occupy an unusually for-
ward position in acute cases even where there
has been no preexisting inflammation to re-
tard development of the mastoid cells. Throm-
bosis might be expected to occur unusually
early in such an instance. A case comes to
mind where I found the sinus crossing the
mastoid at a very high level, as if to connect
the lateral sinus and jugular bulb by the short-
est possible route ; there were more cells be-
low and behind than above and in front of
the sinus ; the antrum seemed especially deep
in a small triangular cavity and was canted at
a peculiar angle, and the nerve, though not
uncovered, must have occupied a high level
in the posterior canal wall to permit the sinus
to go under it to the bulb. The vein, how-
ever, was not thrombosed. Philip Kerrison
has reported such a case. Familial sinus
thrombosis probably has no place in otologic
nomenclature. Yet, I had a case where throm-
bosis of the sinus seemed to be a family dis-
ease, for 2 older children had been operated
on in another city for this complication, and
while the mastoid in my case, the third in
the family, was not especially suggestive of
sinus involvement, the family history impelled
me to explore, and the vein was found to be
thickened and discolored but still patent. By
the extra bone work, customary in such cases,
I was able to avoid in this instance the sinus
and jugular operation. The local bony find-
ings did not emphasize extension by necrosis.
Cheatle, as quoted by Oppenheimer, spoke of
a vein connecting the middle ear and sinus.
Its caliber was sufficient to admit passage of
a No. 1 lachrymal probe. Could this have
been a family anomaly responsible for the
unusual frequency of sinus thrombosis? In
forecasting the position of a sinus, whether
unduly close to or away from the posterior
canal wall, Whiting, it is recalled, stated that
if the mastoid was round and convex, the
sinus was probably close to the wall ; if a flat
mastoid process, it was probably well back.
Hetrick places some reliance on the posi-
tion of the posterior perforated space as
indicative of the downward turn of the under-
lying lateral sinus. In spite of helpful sur-
face markings, most of us by way of reassur-
ance, seem to tip-toe in our operation until
deeper landmarks are revealed.
In closing the anatomic aspect of our sub-
ject, it may be said that in acute otitis media
the center of expansion would seem to be in
the posterior superior region of the tympanic
cavity, from which part cells diverge in al-
most every possible direction. While com-
munication with the mastoid antrum is easiest
in the vast majority of cases, it is conceivable.
24
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
in freak formations, that free intercellular
communication may tend in unusual direc-
tions. Pressure is equal in all directions if
we may apply here the Pascal principle. It
is a matter of resistance to expansion. Cellular
connections may take the process far afield of
the original focus, and at a very early stage
of invasion.
A boy about 12 yr. old came to me with
the story that swelling of the cheek occurred
almost coincident with his ear-ache and ear
discharge. While his ear canal and mastoid
tenderness were not significant of severe mas-
toid involvement, his temperature and face
pain compelled action. Relief was immediate
and lasting in spite of the fact that there was
no unusual pathology in the zygoma. It is
much in the same way that resolution occurs
in Gradenigo syndrome cases after the simple
mastoid operation. Trouble is relieved by
retrogression in many cases if the operation
is carried close to the supposed center of
maximum pressure. Bowers, at a recent
meeting of the New York Academy of Medi-
cine, reported a case of extension in probably
the same manner, because he was able to in-
sinuate a fine probe in the path of the sinus
that extended to the nasopharynx. A post-
pharyngeal abscess was the ultimate thing in
this case, as in one of my own, in a much
younger patient however. The venous plexus
connecting the middle ear and the orifice of
the eustachian tube probably explains the
pathway of infection in some instances (Op-
penheimer). Max M. Kulvin reported a true
case of subtemporal abscess, explaining that
pus determined itself in the zygomatic fossa
because the anterior fibers of the temporal
muscle are loosely attached while the posterior
ones are firmly adherent to the skull. Many
years ago I saw a case that presented pus in
the cheek.
Trauma of the mastoid process that affects •
the underlying cells to the extent of requiring
operation is illustrated by a case I saw oper-
ated on by Elliott Shipman, during my hos-
pital internship. A young adult had been
shot and the bullet flattened out on the mas-
toid process near the tip. The destruction was
extensive enough to justify the simple mas-
toid operation. Imperatori recorded the case
of a baby that developed an operative mas-
toiditis from a fall, the impact being behind
the ear; a sinus thrombosis complicating be-
cause the sinus plate had been fractured.
Many excellent articles, too numerous to
recite, have appeared on the peculiar nature
of the Streptococcus mucosus infection of
the middle ear and mastoid. Guggenheim
and Ferris recently contributed an illuminat-
ing article on this type of infection, entitled
“dry necrosis of the mastoid”, in consonance
with the title chosen by Oscar Wilkinson.
Cases are recorded by others where middle
ear symptoms were lacking, suggesting the
descriptive title of mastoiditis without tym-
panic involvement. Also, under the title of
“atypical mastoiditis”, the odd ways of the
Streptococcus mucosus have been described.
Guggenheim and Ferris introduced their cases
as representing a peculiar form of mastoiditis
characterized by an infection of long duration,
few symptoms and an extensive dry necrosis.
New, I think it was, found that these cases
occur with an infrequency of 1 :500, and it
lias not been my privilege to meet a case with
positively no antecedent middle ear involve-
ment. Some years ago a woman aged 30 came
under notice with indifferent tympanic and
mastoid symptoms, but a low grade headache
on the suspected side, a slight fever and a
hemorrhagic nephritis. Operation disclosed a
mastoid that appeared to be undergoing reso-
lution— not a drop of pus or other secretion
was found — simply a little redness; yet,
threatened chagrin faded as all symptoms
promptly subsided. A 7 yr. old boy, answer-
ing the same type as to symptoms, except
renal irritation, showed the self-same condi-
tion of the mastoid and the same satisfactory
postoperative course. In another instance, in
a girl of 20, the operative findings were totally
different, yet the healing process, though
rapid enough, was almost alarming in its dry-
ness. No cultures were taken and it is un-
fortunate that the organism was not isolated
in any of the foregoing cases. Dry healing
seems not to be mentioned in the reported
cases of dry necrosis and may be quite an-
other infection. Kopetsky thinks that the
Jan , X&31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
25
Klebs-Loeffler bacillus may be the organism
in some of these atypical cases. J. G. Dwyer,
in a personal conversation, stated that the
Streptococcus mucosus may give trouble even
after the ear and wound have healed, the
hypothesis being that trouble starts anew
when the capsule of the organism is dissolved,
possibly a matter of months longer; since the
outlet for the new discharge has been shut
off, intracranial complications threaten.
With a dry ear, a normal canal wall, and
all in all a dearth of local symptoms, the diag-
nostic ability' of the clinician is surely put to
the test. With regard to children an observ-
ant mother may save the day. An ear his-
tory, however remote, may provide the single
clue. Altered appetite of the child, failure to
gain in body weight, morning moisture of the
night clothing, have, singly or in combination,
prompted me to make an investigation of the
mastoid where constitutional reasons seemed
lacking. A night’s sleep that is disturbed, if
only for a little while, may be tell-tale, as
pointed out by Ewing Day, of Pittsburgh.
Misbehavior of peristalsis has been alluded
to very much in recent years and some of the
members of this Section may wish to elabor-
ate on this symptom. As regards adults, Mac-
Kenzie says that most local symptoms may
be absent, but least frequently of all, some
drooping of the posterior canal wall. Many
writers seem to concur in this opinion. With
a dry middle ear, but a suspected mastoiditis,
Hetrick thinks that the Weber-Schwabach
paradox test is of assistance in arriving at a
diagnosis. Again, easily induced fatigue may
suggest the undertow of a long standing but
latent infection. W. S. Tomlin reported a
case of 10 yr. of invalidism and the prompt
gain in weight of 20 lb. after a mastoidectomy.
According to many, audition may be unaffect-
ed, but should always be tested for possible
loss. In these obscure cases it is the indi-
vidual as much as the ear that might disclose
etiology of the illness, bearing in mind that a
systemic something may be found to act as
a herring across the scent and delay the cor-
rect diagnosis of mastoiditis. It is not the
many symptoms in the early phase of the
disease that should concern us, but the lone
and persistent symptom that too often finds
us complacent.
As, between the meaning of white cell and
red cell count, each has its adherents. Latent
mastoiditis, in Hetrick’s analysis of reports,
occurs anywhere between babyhood and
senescence. The period of latency may ex-
tend. as in Bar's case, up to 2 years, perhaps
more. As already quoted from Macuen
Smith, serious pathology is not a surprise.
The radiograph seems to serve its best use in •
symptomless mastoiditis. Granger, in a re-
cent contribution to radiology, described a
technic and interpretation that proved useful
with infants.
It would be superfluous to report some of
mv own experiences when the literature
abounds in illustrative cases. The lack of
tympanic symptoms in these odd cases of
mastoiditis gives rise to the conjecture as to
whether or not they may be of hematogenous
origin. Glogau believes that primary mas-
toiditis is a clinical entity. Taylor, of Jack-
sonville, as quoted by Mallison, cites a case
of mastoiditis developing secondarily to a
bacteriemia, while T. E. Carmody, in connec-
tion with Hempstead’s paper, recalled that a
blood-borne mastoiditis seemed to occur in an
ear opposite to the one he had operated upon.
Classified as atypical and sometimes leading
to operation is the type of case described as
mastoidalgia. My Chief of Clinic was im-
plored by a neurologist to operate on such a
case. In his final letter of refusal he ex-
plained that the best result he could possibly
get would be to restore the ear to the condi-
1 tion it was then in. Byrd, in the course of
conversation, cited a case where there was,
however, a high degree of deafness, actual
pain and occasional watery discharge, and on
operating he found hyperostosis in the region
of the attic and aditus, cramping the ossicles.
After creating room where needed the pa-
tient regained her hearing and enjoyed com-
plete comfort. Harris related an instance
where simply a skin incision yielded a splendid
psychic result. If the maxillary antrum has
now its back against the wall as to normality,
the mastoid antrum, likewise, is seldom a nor-
mal part in the eyes of critical observers.
26
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
i ime and again a radiograph of an unsuspect-
ed mastoid antrum yields evidence of trouble.
When is this antrum well, is a pertinent ques-
tion.
In viewing our middle ears and mastoids
irom another angle, it almost appears that
these parts are susceptible to vasomotor
changes. A young man called at the office
on different occasions with an acutely in-
flamed middle ear and apparently a mastoid
• inflammation. His attacks, while of sudden on-
set, generally disappeared just as suddenly in
a few hours, suggesting an analogy with the
mucous membrane of the nose and maxillary
antrum that balloons and then collapses with
rapidity. Ilaskin, with others, believes that
an abscessed tooth, even without sinus in-
volvement, may alter the course of a mastoid
inflammation. Two cases have come under
my care where extractions seemed to cause
an abrupt turn of events for the better.
Robert H. Fowler believes that there are
carriers of mastoid disease, and I hope he will
explain, while here, his scientific example of
cherchez la femme. Meanwhile, it is hoped that
these scattered remarks on the mastoid and
some of its peculiarities may lead you to tell
of bigger things.
Discussion
Dr. Henry C. Barkhorn (Newark) : It is always
a pleasure to discuss a paper of Dr. Pannell’s. He
has a message, and he gets it across.
Atypical mastoids are the bane of our lives. It
develops that the more mastoids you see, the more
mastoids you do, the fewer are typical if you get
back to your fundamentals. In the infant, the
antrum is at 12 o’clock; at 1 year it is at 1
o’clock; at 3 years it is at 3 o’clock. Naturally,
the child has prolapse of the canal without mas-
toiditis because the antrum is right over the canal.
When a child has a funnel-shaped canal it has
a mastoid; these are the cases that don’t get well
without operation. Of children who have a pro-
lapse of the canal, the vast majority get well on
conservative treatment.
If you follow along anatomic instead of pathologic
lines in your operative procedure, you will make
fewer mistakes. Take out all the cells that may
be diseased, not only the cells that are visibly dis-
eased.
Consider the ear that is apparently normal but
has a history of earache, that has half-headache,
has pain behind the eye; this brings us to the
work that Dr. Eagleton has recently done, and,
by the way, there is an article in the March
Archives of Surgery — not of Otology but of Sur-
gery— by Dr. Eagleton that is of outstanding im-
portance. There are 2 ways that you can get an
apex involvement. One is through the extensive
cellularization of the petrous pyramid. The other
is bv an embolic process. The one is sick from the
very beginning, has a headache out of proportion
to his mastoid findings, may or may not have
Gradenigo’s syndrome, but he gets well in the vast
majority of cases without any further operative
procedure because his is the cellular mastoid. The
other patient has a mastoid, is doing moderately
well, and suddenly has a shot of temperature,
chill, rigor, convulsion if a child, and then has
a pain behind the eye, middle and posterior fossa
syndromes; he has something in the apex of his
pyramid which doesn’t get well. No matter how
extensive your mastoidectomy is, you can’t drain
an osteomyelitis, embolic in nature, in the bone
marrow of the apex. There is where Dr. Eagle-
ton’s operation, of unlocking the deepest portion
of the petrous pyramid, comes into its best field.
He takes away the dural plate, takes away the
sinus plate, takes away the angle of the petrosa,
unlocking the posterior and the middle fossa, he
separates the dura in as far as the apex in the
middle fossa, separates the dura in as far as the
internal auditory meatus in the posterior fossa,
and if there is anything there finds it. That is
the real reason for such success as we have had,
this operation of unlocking the petrous pj ramid.
Dr. Robert H. Fowler (New York): Dr. Pannell
and I worked together in Dr. Rae’s ear clinic at
Manhattan, and in talking over his paper I told
him the following story about a child 4-5 years
old who had a mysterious mastoid infection which
repeated operations failed to clear up. Talking
about affinities — the child’s family was French,
the child could not talk English, and they had
a French nurse who must always be present. It
was not possible for the surgeon to handle the
case and still get rid of the French nurse, so she
was always present with that child. The French
woman and the child were so passionately fond
of one another that it was pathetic to see when
Madamoiselle had to take an occasional hour away
from the bed side. The trained nurses who had the
professional responsibility kept objecting to the
presence of someone who would disturb the diet
and who brought in irregularities and innovations.
The operation had to be repeated more than once,
and the best consultants in town had no sugges-
tion as to why this child should be singled out
more than others for recurrent infections, until one
day Madamoiselle herself came into the office with
a running ear, developed an acute mastoid and
then for the first time acknowledged that she
had been suffering for weeks with earache. As
soon as she was definitely off the case the child’s
mastoid cleared up. The professional nurses
thought that Madamoiselle had been kissing the
child, contrary to orders, and that she was a
carrier. Instead of. a “Typhoid Mary” this was a
case of “Mastoid Madamoiselle”. There was a
curious sequel to that story; 3 months after the
nurse recovered from her own mastoid operation
the question came up as to whether I would be
willing to recommend her to another family as
a child's nurse. T liked this Madamoiselle. She
had been very loyal, she had every virtue that a
human being can have, and had showed a remark-
able affection for the children. But 2 of the chil-
dren in the first family had endured mastoid
operations, and though she was a good children’s
nurse it was a matter of professional judgment
as to whether there was not a risk of her carrying
infection into a new family. There was so much
doubt about this that I found it better not to recom-
mend her. She didn’t get the job but went to work
somewhere else, and now you will be surprised
when I tell you that the child that she did not take
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
27
care of came down with an acute mastoid. So,
perhaps it was just as well for the French nurse
that she had not taken that job and incurred any
question of blame.
This story if it stood alone would mean nothing,
but it does not stand alone. Perhaps you will re-
member that Oliver Wendell Holmes was a doc-
tor, and that he discovered by making observa-
tions in ward work that puerperal infections, post-
partum infections were contagious. That was 60
years ago, and we now take full precautions
against the spread of such infections, but are we
justified in assuming that otitis and mastoid in-
fections are never contagious? I think not, for in
my own practice there have been not less than
half a dozen cases where a patient seemed to get
the mastoid infection from someone near by who
themselves suffered from acute or chronic ear
trouble.
In a ward of 40 mastoid cases in the army 2
things happened that would be surprising if it
were not admitted that certain germs have definite
affinities. It isn’t on the cards, it isn’t in the
books, but the orderly whose job it was to pick
up the cotton in that ward came down himself
with an acute mastoid, and two weeks later 1 of
the doctors, a general medical man who had his
quarters directly across the hall from my own,
came down with an acute mastoiditis and had
to be operated on. From then on, screens were
placed between the beds in the ward and other
steps taken as though the streptococcus was con-
tagious.
This thing doesn’t happen often, but when you
have recurrent mastoids to handle let me advise
you to look with suspicion at those who are in
closest contact with your patient, remembering
my story- — cherchez la femme!
Chairman Emerson : This subject that Dr.
Fowler speaks of is new to me, but it certainly is
something more than coincidence. Last Monday
night, I asked my associate to do a mastoid oper-
ation on a dentist’s son. This dentist has 2 boys.
His other boy has had 2 mastoids, and this was
the second this boy has had. They are the only
children in the family. Incidentally my 2 daugh-
ters had mastoiditis and were operated on 4 days
apart, several years ago, during an epidemic of
measles.
We have often remarked in our work that it
was remarkable that there seemed to be certain
families with 1 to 6 children, in which we have
done in the last 10 years anywhere from 3 to 8
mastoid operations. There are some families in
which all their children, 3 or 4 children, have had
mastoiditis. I have in mind 1 girl, a very strong,
healthy, well-developed, handsome girl, of 12 who
had 7 mastoid operations; 4 were done by sur-
geons in New York before I saw her, and 3 were
done by me in 3 successive years. This child had
an excellent nose and throat,, yet every time she
got a cold, one or the other of her mastoids blew
up.
What Dr. Fowler has said certainly gives us
food for thought. It does mean, as I look back
over our practice of the last 20 years and recall
the numerous families in which we have had
multiple mastoid operations, running as high as
8 in some families, that it merits serious con-
sideration.
People have said to me: “Is mastoid disease
catching, or can this child which has had mas-
toiditis once have it again, or is it more liable to
have it than one who has never had it?” My
answer has nearly always been to all those ques-
tion, “No”, but I believe that I have been mis-
taken, and I believe there is a certain kernel of
truth in what Dr. Fowler has had to say on this
subject.
TONSILLECTOMY UNDER LOCAL
ANESTHESIA*
Robert H. Fowler, M.D.,
New York City
The modern tonsil operation under local
anesthesia is a far, far better thing than those
that preceded it. Bleeding is controlled;
there is no pain, and only slight discomfort ;
the operation is an open one with full visi-
bility at every step, and it is complete, remov-
ing tonsil and infratonsillar nodules to the
very base of the tongue; and, in the most
successful cases the slight trauma leaves the
muscles of the tonsil bed intact.
To obtain these desirable results it is neces-
sary to pay attention to the details of technic.
Not any particular man’s technic nor any one
set of instruments. The improvements I am
about to speak of have been instituted by
many surgeons in different parts of the coun-
try. It will simplify matters to take them up
under the following 14 points :
.( 1 ) Spraying the throat with parasthesin
powder.
(2) Injection of novocain; floating the
tonsil.
(3) Incision.
(4) Grasping the capsule.
(5) Cleaning the white layer of the cap-
sule.
(6) Fibrous attachments freed.
(7) Mucous glands saved.
(8) Upper lobe cleared.
(9) Differentiating and injecting mus-
cular belt.
(10) Sponge placed in fossa.
(11) Shaving off muscles.
(12) Snaring lower pole.
(13) Removal infratonsillar nodules.
*(Read at the 164th Annual Meeting of the
Medical Society of New Jersey, Section of Oph-
thalmology and Rhinolaryngology, Atlantic City,
June 13, 1930.)
2 S
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
( 14) Powder fossa. Tie vessels. Examine
removed tonsils.
The time is short arid it is better to illus-
trate with pictures and speak briefly than to
read any lengthy discussion. (The technic
hereafter described was illustrated by lantern
slides.)
Parasthesin powder full strength is sprayed
on the throat twice with a 2 minute interval.
The surface of 'the tonsil and pillars, and per-
haps the whole pharynx, is included if there
is a persistent reflex. Then 10% solution of
novocain on an applicator wound tightly with
cotton is rubbed over the surface of the pil-
lars and plica triangularis. This is done 3
times at 3 minute intervals, the applicator
being turned or spun in the fingers each time.
Ten minutes later an angular needle is used to
make injections of 1% novocain with a few
drops oi adrenalin added. The object is to
float the tonsil, introducing the needle pre-
cisely where the incision is to be made. The
point of the needle must always be placed
close to the capsule in the theoretic space be-
tween it and the surrounding muscles of the
tonsil so that the solution cannot be absorbed
but will come out at once when the tonsil is
removed. The fluid starts to run out the
moment the incision is made. The initial
prick of the needle can be made barely per-
ceptible, if the point is sharp and the needle
fine, arid the novocain is projected *4 in- al-
ways in advance from there on. It is not
sufficient to flood the upper lobe, that is the
upper pole, of the tonsil, but even greater care
must be exercised in flooding the lower lobe;
and this is, for anatomic reasons, a more diffi-
cult procedure.
Posterior pillar flap. It is difficult to run
the incision straight down the posterior pillar
without tearing the mucous membrane. It
can be accomplished better with a sharp knife
and it is often found possible to shape a flap
to cover in with mucous membrane the upper
quarter of the posterior pillar. Fixation of
posterior pillar is helpful.
Anterior pillar. The incision is carried
dowward over the plica triangularis, saving a
flap of mucous membrane from its surface,
and terminates at junction of the anterior pil-
lar with the base of the tongue. If the whole
of the mucous membrane from the plica tri-
angularis be left in the throat it is often found
to contain lymphoid tissue, infratonsillar
nodules, at the lower third. These can be
seen and the incision can be patterned to skirt
them before reaching the base of the tongue.
Grasping the capsule with forceps is an im-
provement that has lately been introduced. It
has an advantage over the established custom
of seizing the lymphoid mass of the tonsil
tissue, in that it keeps the capsule taut and
gives a higher degree of visibility. The for-
ceps used for this purpose is an Aliys clamp
with box lock and extra grasping teeth. The
white layer of the capsule is the final single
layer of pharyngeal fascia on the north pole
of the tonsil. The more professional certi-
tude displayed in denuding this thin layer,
known as the capsule of the tonsil, without
breaking it, the better chance there is of es-
caping hemorrhage and leaving a protected
wound ; one with enough fascia covering the
muscle's to prevent their becoming infected.
The fibrous attachments are cleared from the
upper pole by meticulous sharp dissection and
the mucous glands with their blood supply
are separated from the tonsil. The lilliputian
attachments are shaved from the tonsil bit by
bit till the pink layer to be left in the fossa
is clearly contrasted with the white dry sur-
face of the upper lobe of the tonsil. When
the upper lobe has been altogether freed the
muscular attachments appear attached to the
equator. It is well to inject these with novo-
cain to cut off a branch from the ninth nerve.
A sponge, half the size of your thumb, is
placed above the tonsil at this time and the
upper lobe of the second tonsil is freed. When
the sponge is removed the muscular attach-
ments at the belt and lower lobe can be shaved
from the surface of the tonsil with a razor
edged knife. By shaving I mean a process of
freeing bit by bit the firm attachments be-
tween the capsule and the tonsillopharyngeus
muscle.
There is an old saying — “beware the
snare-'. That phrase, when I use it, means
use your snare not to dissect muscles but to
sever the lower pole from the base of the
Jan.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
29
tongue and to clear away irifratonsillar
nodules, if any are present, from the lowest
portion of the plica triangularis where it at-
taches to the base of the tongue. These
nodules have come in for a great deal of dis-
cussion lately. When left in the throat they
prevent the clearing up of cervical adenitis.
When the tonsil with the infratonsillar nodules
has been removed, the operation may be
finished by powdering the fossa with bismuth
and tying 1 or 2 of the larger vessels. The
most important one is at the center of the
fossa where the posterior pillar joins the
lateral wall. Instead of a slip knot, a needle
may he used to place a suture under these
vessels.
ADVANTAGES OF GENERAL ANES-
THESIA IN TONSILLECTOMY*
William Campbell, M.D.,
East Orange, New Jersey
Although I am speaking on the advantages
of general anesthesia, I do local anesthetiza-
tion on suitable cases. Looking over my rec-
ords of patients over 16 years of age, I found
that 65% were done under general anesthesia,
but I do not mean to infer that a greater per-
centage could not have been done under local
hut that general was the anesthesia of choice
in those cases.
In neurotic people where apprehension is
apt to be present, there is considerable .mental
shock during local anesthesia. In one case I
know of, a highly strung woman was in bed
for several months following a nervous break-
down that occurred a week or two after the
operation. Where bleeding may be expected,
or where you have an excessive amount of
fibrous tissue, from repeated peritonsillar ab-
scesses, I feel that general anesthesia is easier
on the patient and certainly much easier for
the operator ; and I do not know of anything
more trying than a tonsillectomy under local
anesthesia on a panipky patient.
*(Read at the 164th Annual Meeting of the
Medical Society of New Jersey, Section on Oph-
thalmology and Otorhinolaryngology, Atlantic City,
June 13, 1930.)
In arteriosclerosis and high blood pressure
the use of adrenalin and novocain will some-
times raise the pressure 20 points. In such
types I decide by judging the individual and
have not had any trying experiences either
way. A few months ago I had a 9 year old
girl, referred to me by an internist, with the
history of a congenital pulmonary stenosis
and a rheumatic condition. He did not con-
sider the heart competent for general anes-
thesia, and considered the case a poor risk.
The urine was normal, also the bleeding and
clotting time. I removed the tonsils under
local anesthesia and with very good co-
operation from the child. She had an ex-
cessive amount of adenoid tissue, which was
removed under first stage ether anesthesia. The
child did not have any postoperative- bleeding
from the tonsils, but 10 hr. later had a uterine
hemorrhage of 500 c.c. which was repeated
twice, making 1500 c.c. in all, and did not
stop until after a small transfusion. After
the hemorrhage, cyanosis was gone and the
child never was in shock. A blood count taken
later showed 6,500,000 red cells without any
abnormal findings. I do not know to what we
should attribute the cause of the hemorrhage.
In children, I prefer general anesthesia. I
have seen, several times, uvulectomy and in-
jury to the soft palate result from intract-
ability of the patient under local anesthesia.
Adhesions of the pharynx need only be under
one’s care for relief to make us sufficiently
appreciate the necessity of prevention.
A competent anesthetist and assistant are
essential, and I have not had any complica-
tions, such as lung abscess, etc. Hemor-
rhage, under general anesthesia, will be greater
at the time of operation but you are in a bet-
ter position to control it and in all cases the
throat should lie dry before the patient leaves
the table. I believe you are more liable to
get postoperative bleeding 5 or 6 hours later
after local than after general anesthesia.
I do not see any reason why the actual me-
chanical work, using the dissection and snare
method, should not leave just as good an
after-result whether it be . done under local or
general anesthesia.
I think the outstanding advantage of gen-
30
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
eral anesthesia is the convenience to the oper-
ator.
Discussion
Dr. Theodore W. Corwin (Newark): I think we
have listened to a wonderful description of the
tonsil and tonsil operation, by Dr. Fowler. I am
sorry that our discussion must be limited at all.
One hates to be limited when he has such an op-
portunity for speaking of this wonderful subject.
The demonstrations by Dr. Fowler really very
much simplify the subject. You know from your
own observation and experience that the relation
of the tonsil to the outer wall of the throat is
comparatively little understood. In fact, so far
as we have had to depend on text-books for the
anatomy of the throat, very little has been said
of the external relations of the tonsil, and yet they
are what we are up against. It is to be remem-
bered that the operation of tonsillectomy is really
an operation that is extratonsillar in character. We
don’t operate on the tonsil. It is very important,
therefore, that we should know the external re-
lations of the tonsil.
I have tried to keep up with the methods of
doing the operation. My preference has always
been for the dissection and snare method, using
the snare method a little more freely than we used
to do or than Dr. Fowler suggests. As compared
with other methods, I think the dissection snare
method has very great advantages. The ad-
vantage Dr. Fowler speaks of is notable, in that
you can follow the course of the operation very
carefully. The great point, of course, that Dr.
Fowler has demonstrated, is the existence of mus-
cular tissue which enters from the muscles of the
throat wall into this fibrous capsule or into that
layer of pharyngeal fascia which coinstitutes a
capsule for the tonsil. I know very well that
we encounter difficulty in clearing the tonsil cap-
sule at the equator of the organ, but the ex-
planation before has not been very explicit. Now.
we can go out with an understanding that will
aid us greatly and save us very many compli-
cations.
The question of hemorrhage always comes up.
I don’t want to enlarge upon that except to say
that entry of the blood vessels into the tonsil
occurs through this equatorial region which con-
tains muscle fibers. In approaching the tonsils,
the arterial vessels keep subdividing and attain
small caliber perhaps When right in contact with
the tonsillar tissue of the capsule. If you cut
through the muscular attachment, you encounter
large vessels, comparatively, and you are more
liable to have bleeding. If you are careful to fol-
low the actual surface of the tonsil, as near as
can be, you cut across these vessels when they
are down to a comparatively small size, owijng to
rapid subdivision.
The subject of anesthesia has been demonstrat-
ed beautifully by Dr. Fowler. I notice that he makes
more insertions of novocain solution than I have
been accustomed to, and notably the direct in-
jection to the glossopharyngeal nerve opposite the
lower lobe of the tonsil. That is an important
point to be remembered as even at best under
local anesthesia there are some people who feel a
little pain when the glossopharyngeal nerve is
approached. I have always been accustomed to
giving my patients morphin and hyoscin in such
doses as to make them stuporous an hour before
the operation, and generally patients have no pain
if they attain that condition. The pain is more apt
to develop when the snares are used. That is a
violent process and not only cuts but it also draws
upon the tissues of the throat all around at some
distance from the cutting wire. 1 will say that
local anesthesia can be made very complete in-
deed. I do it for nearly all my operations where
the patient is able to sit up and control himself.
1 think the main part of control is psychic. If
the operator is nervous and fidgety he doesn't have
team-work, and if he shows any apprehension or
awkwardness himself that is sure to be imparted
to the patient. But if an operator approaches with
confidence, the patient will be assured. Things to
be avoided are those which excite the patient. I
think that depression of the tongue is one of the
things you have got to be careful of. I depress
it very little and turn it to one side. If you bring
the tongue in contact with the posterior wall of
the throat you are sure to have some difficulty of
breathing, and that is a thing which is bound to
excite the patient, in the same way, the posterior
wall of the throat must not be touched by the in-
strument. Never swab the posterior wall of the
throat if you want to get along comfortably.
Dr. IT. V. Hubbard (Plainfield) : I have been
rather surprised that there has been no mention
of the toxicology of local anesthesia. Since novo-
cain has come into use there hasn’t been much
question about the toxic effect, although there
have been some cases of mistake in solution used,
and in my experience at the Post-Graudate Hos-
pital in New Y'ork I have seen some instances of
toxic effect.
The method of operation may vary with the
operator. One man gets accustomed to using a
certain form of modified Sluder, and does it very
well, producing good results; and another man
gets accustomed to the dissection and snare, and
he also does the operation very well. So that in
the hands of different men different operations and
good results may be obtained.
Dr. Dikran M. Yazujian (Trenton) : In the mat-
ter of anesthesia I think we should be careful in
lubcrculous cases. I remember seeing at least . 2
such patients who had their tonsils removed un-
der general anesthesia which aggravated their dis-
ease and death followed in a short time. I think
it is a great mistake to operate, on people with
tuberculosis under general anesthesia. We must
draw the line there, I believe: We must always
operate on them with local anesthesia, and I pre-
fer. like Dr. Fowler and others, novocain with
adrenalin in it.
Injecting the tonsil, I find that only 3 points
along the anterior pillar are all we need, because,
the fewer points we inject the less edema we will
get and the less obscuring of outlines of the pos-
terior pillars. I go through the anterior pillar
and inject behind the tonsil in 3 places. The lower
pole of the tonsil we must thoroughly anesthetize
because in my experience it is the most sensitive
part. There is where the patient will have pain
if it is not anesthetized well.
The kind of tonsil syringe is a very small mat-
ter, but I experimented with several different kinds
and the one I found most satisfactory was the Cook
syringe. It is nothing but the frame of a syringe,
as you know, and the novocain carpules come all
ready to be slipped in to take the place of the
barrel. Yrou just take out the used carpule and
slip another one in and it is ready again. Another
advantage of it is that there is no danger of get-
ting your solutions mixed. For instance, if you
have been using cocain for surface anesthesia be-
fore you inject the tonsil, there have been cases
where cocain and novocain have been confused
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
31
and the patient has died from the injection of
cocain. This method avoids all that, because the
carpule comes with the right solution in it and
labeled.
I think we all agree that patients who have had
attacks of quinsy should be given general anes-
thesia instead of local, because there is so much
scar tissue that the local anesthetic will not pene-
trate enough to make the operation painless.
As to the technic of tonsillectomy, after using
dissection, snare and Sluder methods, each for sev-
eral years. I have adopted the La Force technic,
which I have now used for 6-7 years. I prefer it
to the other methods because it removes the ton-
sils, and only the tonsils, cleanly and with much
less bleeding and with much less reaction in the
throat.
Dr. Fowler (closing) : It has been a great honor
to come down here and talk to you and show
these movies to your society. I like to meet men
who are on the frontier of our work, who are
themselves doing the operating day by day and
who are willing to listen to something which may
help them. There is no subject that is numerically
so important as the tonsil operation; it constituted
one-third of all surgery in the United States dur-
ing the last 10 years, and there is no operation we
owe more to in the way of study.
The suggestions that were made in the discus-
sion can be very quickly answered. I have here
something which I think covers 2 at 1 shot. This
is an x-ray film of the lungs of a child 5 % yr.
old whose operation had to be done under local
because, as you will see, the tuberculous process
had destroyed one lung. The doctor who sent the
child into us said that to give ether was out of the
question, the tonsils were very bad and the oper-
ation under local would be. a life saver if it could
be done. The operation was successfully per-
formed, thanks to using the kind of psychology
that Dr. Corwin has suggested. The boy was given
a promise of a boat as a present from his mother
if the first tonsil came out all right. A tear
trickled down his cheek, then he was told that he
could have his choice of another present if he
let the other tonsil come out, and he sent out word
to his mother, after thinking a minute that he
would like a radio on the boat. The mother said
he could have that, and then gently and slowly
the novocain was introduced. I don’t know whe-
ther you have ever seen an operation on a child
well under 10 yr. old of that type, but it was re-
markable with what ease physical removal of the
tonsil took place, and it is remarkable sometimes
to see how these children react to the proper en-
couragement, undergoing what used to be thought
a, very difficult procedure.
Dr. Hubbard, I think it was, spoke of the toxi-
cology. I apologize to you for not having taken
that matter up. It is, I think, the one serious
danger to be thought of and must be considered
by everyone doing local work. Everyone who has
done any of this work has seen either fatalities
from that or dangers of fatalities through the
accidental substitution of a drug, because the 2
clear fluids are on the table in similar glasses, and
the doctor, thinking of his work, gets the syringe
in the wrong glass. This can be definitely pre-
vented by coloring the stronger solution.
Chairman Emerson: How about adrenalin';
Dr. Fowler: Adrenalin I think is very much less
apt to cause fatalities, because the adrenalin is
added by the nurse, say, the 6 drops or whatever
you order beforehand, to the solution, and the doc-
tor isn’t apt to put his syringe into a brown
bottle marked adrenalin. But he is apt to take a
strong solution (10% cocain) that is clear
white and is on the table there next to a weak
solution (1% novocain) that is clear white and
also on the table. These may get mixed at the
pharmacy, they may be mistaken by the nurse,
they may be substituted by the doctor. You have
got to prevent in your local work absolutely any
such thing as that happening or you will have
accidents.
I have seen in New Y’ork 2 actual fatalities in
the hands of doctors of high repute through their
making that mistake, and it is easy to prevent.
You just put a fence around it, if you know what
it is. One of the doctors suggested that a Cook
syringe is the answer. Well, that is one answer,
a syringe with an ampule, where the solution is
made up beforehand. Or, if you prefer to have
another syringe with perhaps a finer needle than
the Cook— it has a rather heavy needle — you can
use the solution fresh from the ampule put into
an open glass at the time.
There is another way, and that is if you have
novocain 10% on your table, or perhaps you choose
to have 10% cocain there, then have it a different
color and you won’t mix them. I always have
my strong solutions on the table blue or red and
so well marked there is no danger. It is known
nowadays that there is no danger in adding a
couple of drops of gentian violet, and that pre-
vents you from substituting the stronger solution
for the weaker injection fluid. That certainly
should have been mentioned in this paper.
A STUDY OF OBSTETRIC
MORTALITY
J. C. Hartman, M.D.,
Germantown, Pa.
As an introduction let me state that some
people say obstetrics has become a surgical
specialty. To this we cannot subscribe, for
the majorit)^ of all deliveries always have been
and always will be conducted by the general
practitioner. The advance that has been im-
parted to surgery through the perfection of
technic, bacteriologic studies and practice of
asepsis, has placed at our disposal a means of
opening the birth canal that was not dreamed
of heretofore. That this weapon has been
used with indiscretion is only too apparent.
Let us for the moment glance at some inter-
esting statistics, concerning the maternal and
infant mortality and morbidity.
First is a report of the New Orleans
Gynecologic and Obstetric Society, which
covers the cesarean sections performed in 6
hospitals of that city over a period of 6 years.
32
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
During- the years covered by this report. 291
cesarean sections were performed and the in-
cidence based on 16,000 deliveries in the same
period was about 2%. More than j/j of those
operations were done by 3 men, 1 an obste-
trician and 2 general surgeons. Only 12%
were done by the transperitoneal low cervical
technic. An analysis of the maternal mortality
from the standpoint of indications for opera-
tion shows that out of 41 eclamptics in the
series 17 were lost, a mortality of 41.5%. The
operation for other toxemic conditions gave
a mortality of 25%. Glancing at the fetal
mortality, one is impressed first by the fact
that out of 55 deaths, 20 occurred in prema-
ture children. Immediately the question arises
whether cesarean section is justified for pre-
mature babies. As a direct result of placenta
p'rbvia 13 children were lost, which is more
than 39%. In this series of 291 cases, 47
mothers were lost, a mortality of 16.1%; 55
babies, a mortality of 18.9% ; and the fatality
was a dual one in 16 cases. Since the above
report, 31 cases were operated upon by the
low cervical technic with no mortalities.
Now let us look at a survey of cesarean sec-
tions in the Borough of Brooklyn during the
same years. In this group there were 934
cases with a maternal mortality of 54, or
5.8%. In 104 cases that were operated on
for eclampsia there were 27 deaths, a mor-
tality of 26%. A fetal mortality of 25.6%.
Among 273 classical operations in which no
vaginal operations had been made there were
16 deaths, a mortality of 5.9%. Among 199
classical operations where vaginal examina-
tions had been made there were 27 deaths, a
mortality of 13.6%, Among 66 lower seg-
ment operations without vaginal operations
there was 1 death, a mortality of 1.5%, and
among 57 of these operations performed after
vaginal examinations there were 6 deaths, a
mortality of 10.5%.
The latest report comes from the city of
Los Angeles, over the years 1923 to 1928 in-
clusive, with a series of 1322 sections, 1060
classic and 262 low cervical, performed in 12
hospitals, with a mortality of 4.2%. In the
series of 1322 cases there were 107 fetal
deaths, or a mortality of 7.9% ; 37 of these
deaths were in premature infants, 6 were
monsters and 5 were still-births. This is a
much better report, but leaves much to be
desired. I wish to give you the indications
for this group of 1322 sections:
Pelvic disproportion . . 488
Eclampsia 46
Premature separation .... 25
Previous abdominal operations 30
No progress ... 112
Cardiac disease „• 38
History of difficulties 29
No cause found 42
Prolapsed cord . . 4
Prolapsed cervix 1
Fetal distress 2 ■
Contraction ring 3
Ruptured uterus 4
Intrapartum infection 1
Intestinal obstruction 1
Recent laparotomy 1
Strangulated hemorrhoids . . 1
Hydrocephalic baby 1
Previous cesarean 197
Preeclampsia 187
Placenta previa 68
Fetal malposition . . 61
Old primiparas . 55
Fibroids 28
Sterilization 27
Insanity 1
Epilepsy 1
Anemia 2
Pernicious anemia 1
Request 4
Thyroid . . . . 1
Diabetes 1
Pyelitis 2
Gain in weight 1
Nervousness 2
Doubled uterus P
Dysmenorrhea 1
Dead fetus 2
Now let us look at the mortality records of
the United States in the past 10 years. In
1915, the maternal mortality rate in the reg-
istered area was 6.1%. In 1920 it was 8%;
in 1927 it was 6.7% per thousand births, and
of this number 40% of all maternal deaths
were due to infection, supposedly a preventable
cause, while 27% are chargeable to eclampsia
and the toxemias. Of the remaining 33%
about 10% may be allotted to dystocia and
operative labor. The remainder may be
credited to the accidents of pregnancy and
labor.
To substantiate the belief that operative inter-
vention increases maternal mortality, listen to
the mortality rate in Massachusetts. In 1901 the
rate of deaths per thousand live births was
3.8% ; in 1905 it was 4.2% ; in 1910 — 4.8% ; in
1915—5%; in 1918—8%; in 1920—7.5%; in
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
33
l°24 — 6%. In an analysis of 1000 fatalities,
death occurred in 225 from puerperal infec-
tion, 217 from toxemia, 140 died from acute
infections, 129 from hemorrhage, 97 died of
embolism, and 49.5% died of heart disease.
Therefore, septicemia, toxemia and hemor-
rhage— causes which are preventable — were re-
sponsible for 58% of the deaths. In 58% of
the cases operative procedures had been re-
sorted to.
With the above statistics before us, that
speak for themselves, let us seek for measures
to brighten the situation: (1) Better funda-
mental obstetric teaching in our universities.
(2) More careful supervision of our residents,
Leaching them how to observe the normal.
How many instances do you see where the
resident physician is only called just in time
to put on his gloves and tie the cord. He, in
his youth and enthusiasm, feels that to get
anything out of his hospital training he must
do forceps, version, episiotomies and all the
operative procedures connected with the ser-
vice. Unfortunately, in many institutions he
is aided and abetted in his desire by careless-
ness of his superiors, either on the staff of the
hospital, who are not doing special obstetric
work, or by the courtesy staff if it happens
to be an open hospital. He should be taught,
first, the dangers of operative interference and
made to observe the normal physiologic me-
chanism of labor, so as to appreciate when the
normal is at fault, and to expect help when
this mechanism is abnormal. The more he is
made to appreciate the dangers of operative
interference the better will be our maternal
mortality, when he joins our midst as a prac-
titioner.
Prenatal care. Here I wish to consider
principally eclampsia and preeclampsia. From
the foregoing statistics I am sure you are all
convinced that cesarean section has no place
whatsoever in the treatment of eclampsia. In
most of these cases the child is dead from the
toxemia or is premature and death occurs soon
afterward. These cases are treated with
greater safety to mother and child by early
hospitalization, complete rest, dietetic and
-eliminative measures with induction of labor
in the preeclamptic stages. If eclamptic, the
recognized procedures, such as morphin in
massive doses, elimination by bowel and
stomach, glucose, magnesium sulphate, and as
normal a delivery as possible. Since 27% of
our maternal mortality is charged to toxemia
we would do well to increase our carefulness
in prenatal care. Insist on the patient follow-
ing directions as to diet, amount of water in-
gested, keeping the avenues of elimination
open and strict attendance at your office as
often as necessary to check the blood pressure
and urinalysis. In your prenatal study be
careful to eliminate all possible sources of
focal infection. Remember we do not know
the cause of eclampsia, and that all our ef-
forts must be toward elimination and lighten-
ing the burden of the kidney and liver.
In hospitals with well regulated out-patient
departments eclampsia is almost entirely eradi-
cated ; it is rare to see such a case but the in-
cidence is just as great as ever. Therefore,
this 27% of our mortality must be placed at
the door of careless prenatal care and un-
sound surgical judgment.
Unnecessary cesarean section. As you
listened to the indication for cesarean section
in the Los Angeles statistics, did it not sound
like a High School farce ; picking out some of
the high lights — fetal malpositions, old primi-
paras, sterilization, request, pyelitis, nervous-
ness, dysmenorrhea, dead fetus, history of
difficulties, no cause, no progress, cardiac dis-
ease, etc.? I am sure that out of 1322 sections
more than one-half of them were not justified.
When you realize that clinical experience has
taught us that 60 to 80% of the labors in
relatively, contracted pelves terminate spon-
taneously, you can lop off in a stroke 288 of
the 488 done for contracted pelvis. Eliminate
233 done for eclampsia and preeclampsia, and
about 400 for foolish causes, and the ever
present desire to operate, and you will agree
that my estimate of one-half is low.
With reference to complicating disease in
pregnancy, the pregnancy in most instances
can be disregarded and attention given to the
treatment of the disease. Here again let me
reiterate that cesarean section has no place in
the treatment of eclampsia.
Cesarean section in the treatment of pla-
34
JOURNAL OF THK MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
centa previa has a definite place. In central
placenta previa it is indicated in all cases,
primipara and multipara. In the marginal and
lateral types the method of treatment is one
of choice, especially in the multipara where
we expect less difficulty in opening the birth
canal. The condition of the cervix always
guides our choice, if it is a long, hard snout-
like affair and the baby alive, cesarean may
show the best judgment. The condition of
your patient is not the guide for your proced-
ure. If she is in shock, treat her for that
by intravenous injection of salt solution, glu-
cose acacia or blood transfusion, before any
operative procedure is undertaken. Simple
rupture of the membranes with the jamming
of the presenting part into the cervix is often
sufficient to control the hemorrhage and labor
terminates spontaneously. Statistics show
that where cesarean is done in routine for all
previas, fetal mortality is markedly raised, as
so many of these infants are anemic from loss
of blood and unless immediately transfused
die within a few hours, whereas you have
subjected the mother to more serious danger,
from infection, especially if she has been ex-
amined vaginally or, as often is the case, has
been packed with any and everything in the
emergency. All cases of placenta previa
should be hospitalized as soon as the diagnosis
is verified, so as to treat the woman asepti-
callv and guard against loss of blood, which
in turn lowers resistance and favors develop-
ment of infection.
Malpositions. The incidence of cesarean
section is steadily increasing for this compli-
cation and is very unjustifiable. It is done for
occiput posterior, breech, brow, face, trans-
verse and every possible presentation. This
incidence is due in great measure to the gen-
eral surgeon, called in consultation, not being
trained in obstetrics, who does the thing that
he can do best — a surgical operation, ces-
arean section. In these cases it is better to
consult the obstetrician who is trained in the
mechanism of labor and who realizes that
malposition is only one chapter in the patient’s
obstetric career. Cesarean section relieves the
present situation but places the mother’s life
in jeopardy for all future pregnancies, as she
has a 14% chance of the scar rupturing. I
am not blaming the surgeons, as he extricated
himself with the best weapon at his disposal,
but if fear of the patient being removed from
possible hospital care or receiving inadequate
medical attention was present in our conscience
we would seek another way out, because a
cesarean predicates future demands for the
highest type of attention and skill. Here again
the finger of accusation points to lack of pre-
natal care, for in a good prenatal clinic with
examinations and palpation 2 or 3 weeks prior
to delivery, you will detect the abnormalities
when correction can be made, or if not cor-
rected you know what you have to deal with
and are prepared to carefully guide. labor from
the onset.
Elderly primiparas. The dangers and diffi-
culties of labor in elderly primiparas have been
greatly exaggerated, for statistics show that
neither fetal nor maternal mortality is increas-
ed above levels generally accepted as normal
and the average duration of labor is only
slightly prolonged, while 20% of the women
have strikingly rapid and easy labors. Dys-
tocia may be expected in about 15% of cases,
and in most instances it is not a true dystocia
but a weak uterine contraction that fails to
dilate the cervix. These cases are helped
tremendously by Gwathmey analgesia where
the painful inefficient contractions are relieved
long enough to allow the real expulsive second
stage pains to begin.
Development of the low cervical cesarean
should lower this cesarean incidence by allow-
ing patients to have a test of labor. If this
is practiced most of these cases will deliver
spontaneously. Many think that a test of
labor is just so many hours. My idea carries
with it, the condition of the patient, frequency
and duration of the pains, their impression on
the cervix, and whether they are of the ex-
pulsive or the hugging type. No definite
length of time, 4 to 18 hours, but a careful
personal observance of the patient during the
test period, controlling nervousness and ap-
prehension of the patient with sedatives and
trying to ascertain her obstetric ability; plac-
ing no weight on the patient’s outcry.
A certain percentage of cesarean sections
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
35
will always be done in these elderly primiparas.
due to long standing sterility and the increased
value placed on the child.
The foregoing shows that too many sections
are being done. It carries a greater mortality
and morbidity than any other clean abdominal
operation. The mortality ranges from 1.8%
in clean cases in which operation has been per-
formed before the beginning of labor to
27% in cases in which forceps have failed and
the membranes have been ruptured for any
considerable length of time; while the mor-
bidity ranges from 33 to 70%.
Now let us pass on to another cause of ma-
ternal mortality and morbidity and a high
fetal morbidity — use and abuse of forceps
and the abuse of pituitrin. The application
of forceps still goes on. without any definite
idea as to presentation or position of the pre-
senting part to the vaginal canal. High, med-
ium or low forceps, with utter disregard to
the efifacement and dilatation of the cervical
-canal, and a lack of any sense of disproportion
between the presenting part and pelvic inlet.
Only the other night I was called in consulta-
tion where forceps had been applied and slip-
ped off 3 times, on an R. O. P. above the in-
let, with the cervix uneffaced and only par-
tially dilated ; entire pelvic diaphragm eviscer-
ated out of the vagina, bladder not catheter-
ized, the cervix cut in 8 different places, and
the fetal skull crushed. This in a young
primipara, with a normal pelvis, in labor only
12 hours.
Forceps should never be applied above the
pelvic brim and only in extreme cases when
the head is in the mid-pelvis. Low forceps as
your judgment and ability direct. All should
be used with great aseptic care and emulating
nattire as much as possible. The arrested
high heads should be converted into the an-
terior positions and allowed to descend. In
the minor degrees of contracted pelvis the in-
duction of labor 10 days or 2 weeks early
gives excellent results, especially in multiparas.
Pituitrin is still given in massive doses — -1,
2 or 3 ampules at a time in one labor; given
when the cervix is undilated, when the uterus
is already undergoing strong contraction ;
given without reference to fetal and pelvic
disproportion, causing ruptured uteri, cervical
tears and hemorrhage, and increasing the fetal
mortality by intracranial hemorrhage. Pituitrin
should be used with great care and in minute
doses, and only when labor ceases to advance
because of uterine dystocia. After rupture of
the membranes it should be used with extreme
caution; never in disproportion of head and
pelvis or in thick rigid cervices.
In conclusion, let me say that statistics show
90 to 95% of all labors terminate spontan-
eously, and that the higher the incidence of
operative interference, whether done by the
expert or the general man, the greater the in-
crease in both maternal and fetal mortalities.
Therefore, let us increase our prenatal care,
be sure of our knowledge of the physiologic
mechanism of labor, practice rigid aseptic
technic, keep our conscience ever present, de-
crease our interference with normal labor by
such instruments as forceps, version and
pituitrin, and only use cesarean section after
good obstetric consultation.
A FEW PROBLEMS IN MEDICAL
ETHICS*
Harry H. Bowles,
Summit, N. J.
I wish to express my sincere thanks to the
members of this society for the kindness and
cooperation they have extended to me during
the past year. I know that I have not been so
efficient as I should have been, yet you have
all been so helpful and considerate that the
cares of office have seemed more like a pleas-
ure than a burden.
One must be bold indeed to dare a dis-
cussion of medical ethics. It has been worn
so threadbare by repeated handlings that
everyone raises an eyebrow when it is men-
tioned.- Hence, lest your patience be too sorely
tried, I shall make this reading very brief.
In the first place it has been, and can still
be, said that the right sort of medical man
needs very few rules of conduct, while the
* (Presidential Address at the Annual Meeting of
the Summit Medical Society.)
36
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
wrong sort will be bound by no rules, how-
ever rigid they may be. In the last 35 years
there has been tremendous progress in the
practice of medicine, also in governmental
structure and industry, so that many import-
ant things have happened to affect the rela-
tions of physicians to each other and to the
public. One important phase to be mentioned
is the employment of doctors by societies,
which undoubtedly has a cheapening influence
on the practice of medicine. Insurance and
fraternal organizations frequently employ
physicians to do family practice in a whole-
sale way. Corporations made up of laymen
employ physicians, and advertise in a com-
mercial- manner to attract patrons. Many
practitioners are listening to the siren voice
of quick money, obtained with little expendi-
ture of energy; thus presenting some new
problems for medical societies to solve.
Where strictly mercenary organizations are
concerned, we know the old rule of ethics ap-
plies directly. The problem is chiefly con-
cerned with borderline cases, where, for ex-
ample, a corporation employs physicians on
salaries, supposedly to treat indigent cases yet
not excluding those which should pay a physi-
cian’s regular fee. The question which pre-
sents itself here is — can a physician aiming to
be ethical become identified with such organi-
zations ?
Another problem is that of friction which
sometimes occurs between physicians of health
departments and the family physician. Neith-
er is at fault, but trouble is caused as a rule
by introduction of the newer methods of pro-
phylaxis, vaccine therapy, and so on. Cer-
tainly there is some cause for debate as to
where the duty of the Health Department
ends and that of the family doctor begins.
The problem requires tolerance and under-
standing for its remedy and no rule of ethics
can govern it entirely.
To speak frankly it is common knowledge
that a considerable portion of the people are
not getting the highest type of medical ser-
vice. And this is not because of a lack of
kindness or altruism on the part of the pro-
fession. Medical men still retain the whole- -
souled generosity and charitable feelings they
have always had, and I think always will have
to the end of time. The difficulty appears to
lie in the fact that there is a lack of coordina-
tion between practitioners and health organi-
zations. In the complex civilization in which
we now live, individualism has given way to
coordinated effort in other lines of community
endeavor. The administration of public
schools, the building of roads, the regulation
of transportation, the regulation of food and
drugs, by governmental agencies must meet
with our approval. The interest of the gov-
ernment in prevention of the spread of com-
municable diseases, the control of water sup-
plies and sanitary movements, is certainly
to be commended.
Thus it would seem the government takes
care of preventive medicine, the private physi-
cians of curative medicine, and it is hard to
draw a definite line between them. This
small rift or lack of coordination of practicing
physicians with health boards and other gov-
ernmental agencies, some fear may be an ex-
citing cause of ill-advised agitation for state
medicine. We have all witnessed the spectacle
of state medicine in Europe threatening to
demoralize the whole practice of medicine.
Some thinkers fear it may seep in here,
though we hope not. I believe that state medi-
cine would be disastrous for the profession
in America and that we should be on the alert
to nip it in the bud, should that become neces-
sary. We should endeavor to cooperate with
all local and state health organizations for the
advantage of both sides. I am sure that the
profession, so carefully trained as it is to-
day, can cope with the situation. We have
eaten of the fruit of the tree of knowledge.
It remains for the present and succeeding
generations to demonstrate that knowledge
has been wisely used for the healing of peoples.
We must cease to be individualists and must
work in splendid cooperation for our fellow-
men.
Before passing on from this phase of the
subject, I merely wish to add that credit must
be given to health boards for popularizing,
through publicity, the periodic health examin-
ations of children and adults. These examin-
ations, incidentally, eventually add to the in-
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW TERSEY
37
come of private physicians. One state, to my
certain knowledge, is trying to institute a
system through its health boards, whereby the
examination of children of preschool age may
be gradually transferred from the domain of
the school physician to the family physician.
The radio is now being used a great deal
for broadcasting important news items to the
world. Of course, it is employed in giving
to the public' many important fact's regarding
scientific medicine and the prevention of dis-
ease epidemics: It is perfectly proper for
health officers to use the radio in broadcast-
ing such news but what about the private
physician in a similar situation ? When the
latter’s name appears upon broadcasting pro-
grams, even if' Inis "meaning is good, he is
subject to criticism in the medical family.
However, if the occasion were to arise, so that
it would seem necessary for one or more mem-
bers of the practicing fraternity to broadcast,
it might seem more fitting for the local medi-
cal organization to select the speaker or speak-
ers,' thus avoiding any embarrassment.
Another point to be mentioned, we have
among the fraternity a few men (fortunately
few) who seem to us to be rather heavily in-
clined toward the commercial side of medi-
cine. These are often the gentlemen with the
grand autos, the brilliant plumage, the well-
curtained waiting rooms— in short all the
“window dressing”. These are the gentry who
call every abdominal pain appendicitis, every
belch a gall-stone, every heart-burn, an ulcer.
Their practice is large, their income huge, their
cures miraculous, in the minds of their grate-
ful patients. Again, we have the men, and
often able men they are, who are endowed
with multi-cylindered egos, flavored with
avarice, and who exact the ultimate farthing
from their patients. These fellows pretend
to justify such practices by saying they have
rendered unusual service, and that large
charges impress the patient with the prestige
of the physician. Such acts, of course, vio-
late the ethics of practice as much as secret
fee-splitting and reflect on the profession as
a whole.
A little aside from or indirectly related to
ethics, yet a phase which medical men should
be interested in, is the experiment which is
being made to reduce the cost of medical care
and hospital expense to the' people of mod-
erate means, who do not wish charity, whd
wish to pay a moderate fee but who cannot
pay the regular fees of hospitals and high
priced specialists. Of course, all fair minded
medical men would charge but nominal fees
to such patients, but what about the hospitals ?'
In some of the larger centers efforts are being
made to furnish such moderate wage earners
with reasonable care, such as combined hos-
pital and medical care at $4 to $6.50 per day.
Recently there has Ijeen added the Baker Me-
morial wing of the Massachusetts' General
Hospital to take care of such cases. Presi-
dent Embree, of the Rosenwald Foundation,,
at the dedication of the Baker wing spoke as
follows: “Under conditions of poverty and
dependence, charity was a virtue, a human
necessity. Today the citizen of America does
not require alms, he does not want charity. He
wants and rightfully demands that in medical
treatment, as in the other necessities of life,
agencies be so organized that service will be
good and efficient and costs correspondingly
low. lie demands this service be not doled out
to him as charity but that he be allowed to paV
a reasonable and proper cost. Under new con-
ditions hospitals should cease to boast of their
medical charity, they should take increased
pride in striving to have all their services so
organized that each patient, even the low wage-
earner pays as he goes for what he gets.”
These words, bear in mind, were spoken
before the great slump in business and vast
unemployment came. And the Baker Me-
morial started with $1,000,000 endowment
and during the first 3 years the deficit will be
one-half underwritten by the Rosenwald fund.
It will be interesting to watch this and similar
experiments.
In conclusion, I wish to say that medical
men follow a code of ethics which originated
in olden times. This code was constructed
on the principle of fair dealing of doctor to
doctor and doctor to patient. By holding to
this code of ethics we can maintain the
humanitarian standard on a high plane. In
this talk I have meant to be entirely imper-
38
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
sonal and have not meant to infer that the ten-
dency of modern medicine is as a rule mercen-
ary. Perish the thought. The vast majority of
the fraternity are splendid, ethical men ; the ex-
ceptional ones are to be considered in some way,
I don’t know how. That will be the problem
of the societies in the future. In the rapid
progress made of late years in all lines of
business and the professions it is strange that
the adjustments have been so smooth as they
have been. It is the duty of such societies as
this to help in ironing out the rough spots and
paving the way for a broader understanding
of physicians to each other, to the profession
as a whole, and to the public in general.
A BACTERIOLOGIC STUDY OF
CHRONIC INFECTIOUS
ARTHRITIS
John W. Gray, M.D., and
Cecil H. Gowen,
Newark, N. J.
During the past year certain clinical and
laboratory observations have been made in the
Arthritis Clinic at the Hospital of St. Barna-
bas and in private practice, which seem of
sufficient importance for at least a preliminary
report. The clinic was started primarily for
the study and treatment of chronic infectious
arthritis (arthritis deformans).
Cecil, Nicholls and Stainsby1 did extensive
work on this subject. They isolated a strep-
tococcus from the circulating blood of pa-
tients with chronic infectious arthritis in
61.5% in a series of 7S cases, which organ-
ism they considered a specific strain in 83.3%.
They also found that streptococcus, culturally
and biologically identical with the strain iso-
lated from the blood, could sometimes be iso-
lated from a focus of infection and in affected
joints in the same patient.
Cecil’s technic was duplicated and results
similar to his were obtained in our laboratory.
It was very difficult to get the organism
started in primary cultures, as shown by the
fact that an average of 17 days’ incubation
was required in his series. One of our posi-
tives developed on the twenty-eighth day.
There was always the suggestion on the part
of critics that because the containers had to
be opened so many times for subculturing we
might be dealing with contaminations. Such
a conclusion was highly improbable because
we were getting a fair percentage of strep-
tococcus growth of uniform type, only an
occasional culture showed staphylococcus and
diphtheroid organisms, and normal controls
showed the same number of contaminants but
no streptococcus. Furthermore, Cecil had
thoroughly checked his work by animal in-
oculation and cross agglutination. However,
when tve hit upon a modification of the media
about 3 months ago zvhich produced positives
in the form of diffuse clouding of the media
in 1 to 4 days without opening the bottles,
the criticism above mentioned was eliminated.
This method which consistently showed more
positives than any we had tried, and all in a
comparatively short time, presented numerous
other advantages from both research and clin-
ical standpoints.
Cecil’s Plan of Culturing
The patient’s arm is prepared by 2 coats of
iodin and washed off with alcohol and 20 c.c.
of blood is drawn from a vein in the arm and
placed in 2 sterile dry test tubes ( 10 c.c. in
each). These are placed in the ice box over
night. The serum is removed, clot broken
up, and the pieces of clot placed in each of two
100 c.c. bottles containing 50 c.c. of media.
The bottles are incubated for 30 days and sub-
cultures are made on blood agar every 5 days.
The media is prepared as follows: Fresh beef
heart is freed from fat and fibers, ground
finely in a meat chopper and infused at ice
box temperature over night, using 500 gm.
ground meat and 500 c.c. tap water. Next
morning the infusion is warmed to 20-25° and
squeezed through a flannel bag. The filtrate
is then boiled slowly for 1 hour and filtered
through paper. It is then made up to volume
and 1.5% peptone and 0.5% NaCl added.
This is then placed in the Arnold, for 20-25
minutes to dissolve the peptone and salt. It is
then titrated to pH 7.8 and placed in the
Arnold for 1 hour. It is filtered through
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
39
paper and retitrated. If the pH has dropped
it should be retitrated to 7.8 and put back
into the Arnold for another hour. Then 50
e.c. of the media is placed in 3 oz. bottles and
sterilized 34 hour in the Arnold for 3 suc-
cessive days. It is titrated again and, if it has
a pH of 7.6 or slightly above, it is satisfactory
for use; if below 7.6, it is unsatisfactory. The
finished product should be incubated several
days for sterility.
Modified Method
Preparation of the infusion is exactly the
same as above. At the end of the boiling and
filtering, 0.5% NaCl, 1% gelatin (Bacto),
1% glucose (c.p.) and 1.5% peptone (Wittes)
are added. This is placed in the Arnold for
20 minutes and titrated to pH 8. It is then
placed in the Arnold for 1 hour and retitrated.
If below 7.8 it is adjusted to that figure and
placed in the Arnold for an hour. It is filter-
ed through paper. It should not be below a
pH of 7.8 before placing in bottles. The bot-
tles are prepared beforehand by placing about
a teaspoonful of calcium carbonate (c.p. pow-
dered) in each of them, plugging with cotton,
or cheese cloth and cotton, and sterilizing in
the dry sterilizer for 1 hour. In these sterile
bottles 50 c.c. of the media are placed and ster-
ilized in the Arnold for 30 minutes on 3 suc-
cessive days. At the end of 3 days it is
titrated and if the pH is 7.6 to 7.8 it is satis-
factory. It usually shows a pH of 7.7 to 7.8.
The calcium carbonate helps to keep the media
from becoming more acid while being steril-
ized. If the pH is correct it is placed in the
incubator for several days and if sterile is
then ready for use.
Description of the Organism
While the growth is young, long chains are
formed which cloud the whole medium. As
the culture gets older this clears and the or-
ganism breaks up into small chains or even
diplococci and settles to the bottom of the con-
tainer. Initial transfers into brain broth
(Difco) or blood brain broth show the same
characteristics. Transfers into a meat in-
fusion medium (plain broth) form sand-like
flakes which adhere to the side of the tube or
settle to the bottom leaving the medium per-
fectly clear. After several transfers in this
plain broth the organism diffuses through the
medium, producing a uniform cloudiness.
Long chains which appear in cultures of an
enriched medium, such as brain broth or gela-
tin dextrose broth, each chain sometimes con-
taining as many as 30 to 50 cocci, break up
after 24 to 48 hours. The chains are much
shorter (6-12 cocci) in plain broth but do not
break up until 60 to 72 hours have elapsed.
After several transplants the organism tends
to grow uniformly in chains of 6 to 12 cocci.
On blood agar there is a very delicate growth
which shows a definite production of methem-
oglobin. This is a very pale green and does
not diffuse into the medium but is beneath and
immediately surrounding the colony. The
colony itself is a dirty grayish color. There
is also a small zone of partial hemolysis sur-
rounding the colony after 48 hours incuba-
tion which is much more pronounced around
the colonies deep in the medium.
Blood Cultures for Streptococci
No.
No.
No.
No.
Clinical diagnosis Cases
Cultures
Neg.
Pos.
Normal individuals
5
5
5
0
Chronic ulcerative colitis
2
2
2
0
Acute appendicitis
1
1
1
0
Hypertension
1
1
1
0
Purpura hemorrhagica
1
1
1
0
Carcinomatosis
2
8
8
0
Diffuse peritonitis
1
1
1
0
Septic abortion
2
2
2
0
Typhoid fever
1
3
3
0
Cavernous sinus thrombosis
1
2
1
1
Malignant endocarditis
1
4
2
2
Acute peritonsillar abscess
1
1
0
1
Agranulocytic angina
1
3
2
1
Myositis
1
1
1
0
Sciatica
1
1
1
0
Gonococcal arthritis
2
3
3
0
Hypertrophic arthritis
5
13
13
0
Subacute osteitis
1
, 1
0
1
Chronic infectious arthritis
2
2
1
1
(Fluid from knee joint)
Chronic infectious arthritis
37
59
34
25
(blood)
The above table includes febrile and non-
febrile conditions as controls. The malignant
endocarditis and quinsy cases showed positive
growths of streptococcus which could not be
culturally differentiated from the “arthritic”
strain. The positive culture in the case of
cavernous sinus thrombosis was a typical
Streptococcus viridans. The patient suffer-
ing with agranulocytic angina had a septic
throat and pyemic abscesses. Hemolytic
streptococcus was found in the blood culture.
40
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
The subacute osteitis case was of unusual in-
terest because of its close clinical and bac-
teriologic relationship to the infectious ar-
thritic group. The patient complained of
moderate pain in the lower thigh for
about 4 months, had a low grade tempera-
ture and radiograph showed thickening of the
bone. Three diseased teeth were extracted
soon after the onset. Vaccine was prepared
from the “arthritic” type streptococcus iso-
lated from the blood. The streptococcus re-
covered from the knee fluid was identical, cul-
turally and morphologically, with that re-
covered from the blood stream and occurred
in one of the cases listed under chronic in-
fectious arthritis, a woman of 56 years who
gave a history of arthritis for 15 years and
was badly deformed.
The chronic infectious arthritic group of
37 cases in which 59 blood cultures were taken
showed a positive growth of the “arthritic”
streptococcus in 67.6% of the cases and 42%
of the cultures.
The cases placed in the above group showed
many variations but were sufficiently typical
clinically to be so classified. They all had
multiple arthritis, most of them typical fusi-
form swelling of the smaller joints and many
had deformities. The youngest was 14 and
and had suffered involvement of the joints of
the hands and feet for 4 years (Still’s dis-
ease). The oldest was 75, the average age
44. The duration of illness was from 3
months to 25 years ; the average duration being
5 years 2 months; 29 were females, 8 were
males. Several cases classified as chronic in-
fectious arthritis showed interesting varia-
tions. Two patients, a woman of 40 and a man
of 60, had severe bilateral rheumatic iritis
which developed prior to onset of arthritis.
Both gave histories of severe sinusitis. One
patient of 29 first noticed pain in one finger,
developed tenosynovitis with a “trigger” finger
and subsequently typical arthritis. Three gave
histories of rheumatic fever or allied condi-
tions in childhood; 2 of these had definite at-
tacks of rheumatic fever, 1 had chorea and
myositis. All had rheumatic cardiac signs. In
1 . interphalangeal joints of the hands showed
fusiform swelling typical of early deforming
arthritis, while the other 2 had multiple de-
formities. Two showed “arthritic” strep-
tococcus in blood cultures. We are not in a
position to determine whether the rheumatic
fever infections or secondary infections were
the etiologic factors in these cases.
Of the chronic infectious group, 30%
showed definite foci in teeth, tonsils or
sinuses. In the hypertrophic group no his-
tory or evidence of foci were found.
Cecil recently stated that patients with typi-
cal chronic infectious arthritis show high
agglutination for the typical arthritic strains
in 94% of cases. This would be important
not only in proving the specificity of the or-
ganism for this type of arthritis but also in
differentiating border-line infectious and non-
infectious types. We have examined most of
our cases for agglutination of these organisms
and find that many of the bloods show a posi-
tive result to a high titre. However, no fur-
ther report of this phase of the work can be
made until proper controls are carried out.
Chronic infectious arthritis is undoubtedly
due to a streptococcus infection of the joint
tissues caused by a blood stream infection
from a primary focus such as the sinuses, teeth
and tonsils. Probably some patients control
foci in the joints without any treament, others
apparently recover when the primary focus is
removed, but the great majority do not con-
trol the secondary foci in the joints and stead-
ily or intermittently progress toward deform-
ity and invalidism.
Vaccine therapy has been persistently used
in the belief that it would have a specific action
on the joint infection. The vaccine was pre-
pared from the “arthritic” streptococcus iso-
lated from the patient’s blood or from prim-
ary foci, or both, or from typical strains in
case an autogenous vaccine could not be ob-
tained. A primary dose of 200 million was
given, increasing that amount each week until
2000 million was given as a maximum dose
and that amount was continued indefinitely
unless a reaction occurred. Because of re-
current attacks in 2 patients while on this
regimen, focal or general reactions were con-
sidered indications for reducing the dose. The
most important single observation regarding
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
41
vaccine therapy was that it must be used for
a long period of time. One must have a great
deal of confidence in this method of treat-
ment to encourage patients to continue injec-
tions for months with little or no apparent
change in the joint picture. But we have been
repaid for persistence in many instances by a
sudden improvement which progressed to an
apparent cure.
However, one should not expect too much
from vaccine alone. Some patients are acute-
ly ill and require hospitalization. A large
number are poorly nourished and require a
high caloric diet. Two patients who had in-
sufficient vitality to respond to vaccine or any-
thing else were given initial transfusions.
Many patients find it necessary to continue
work, using up every ounce of their reserve,
when they deserve long continued rest. Fa-
tigue should always be avoided. A warm, dry,
equable climate is ideal. Although we are par-
ticularly interested in prevention of deformi-
ties through early and possibly specific treat-
ment, there are thousands of crippled people
who could be infinitely improved through
proper physiotherapeutic and orthopedic treat-
ment. They cannot receive adequate treat-
ment at home and there are few hospitals
for the care of such patients as cannot afford
a private sanatorium.
It is obvious that because the group of cases
treated was small and because of the short
time they have been observed no final con-
clusion can be made until a later date. Nor
would we venture too far in making con-
clusions regarding: the cultural study, but we
do feel that the method above described for
the quick growth of organisms from the blood
of patients suffering from chronic infectious
arthritis is of sufficient importance to be
brought to the attention of other workers at
this time.
References
• 1. Cecil, R. L., Nicholls, E. E., and Stainsby,
W. T.: Bacteriology of the Blood and Joints in
Chronic Infectious Arthritis, Arch. Int. Med., 43:
571, 1929.
2. Cecil, R. L. : A Modern Conception of Arth-
ritis, Jour. Lab. and Clin. Med., 15:1177 1930.
TODAY
Yesterday, I know not how,
I slipped out from Then to Now.
Such a world before me lay,
Growing fairer every day,
’Til this morn I pause to count
All my wealth — a vast amount :
Friends, the love that round me lies,
Flowers and birds and sunset skies,
Memories of what hath been,
Hope for days that wait unseen;
But the best in every way
Is the gift of each new day !
Every morn for me it waits,
When I drift through sleep’s dim gates.
None may hasten, none delay,
None may spend it — My Today.
So this little prayer I raise
For today and all the days :
Joyfully may I fare forth,
Make each swift day full of worth,
Work and love and pray and live
And myself for others give.
So may life be richer when
I am sped from Now to Then.
Frances, C. Hamlet.
42
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
Special Article
MEDICAL TRAVEL TALK
A Physician’s Vacation in Ireland, England
and France
Henry O. Reik, M.D.,
Atlantic City
Physicians find it more difficult than any
other class of workers to take a real vacation,
if by that word one means putting aside
thought of the daily occupation, for the prac-
tice of medicine is not only a noble profession
but a very exacting one, and when one becomes
wedded to it he finds himself bound to a jeal-
ous mistress who demands constant attention.
and explorations. A short post-graduate
course of study may be made to serve the
purpose of vacation, as may also attendance
upon some national or international medical
convention. Or, inasmuch as travel has both
a vacational and educational value, even an
informal trip into distant states or other coun-
tries may prove profitable if combined merely
with observation, from a medical point of
view, of the habits and customs of other peo-
ples. It was with some such vague idea in
mind that we planned this summer’s vaca-
tion ; we had no desire to listen to the reading
of scientific papers, nor to attend clinics, but
we believed it might be possible to pick up
some information concerning the working of
national health insurance laws — sometimes
referred to as State Medicine — while at the
same time enjoying the delights of travel, and,
*!* :
sfsaasB'.v-'sr :
.. .
m ilia
■■ fmm*
r :
i gsiiti ' v
*»K m
win
ii 81
IS
Fig. 1. Village Dispensary. District medical service to the poor: under a very old law.
On the other hand, no group of workers de-
serves more than physicians or is in greater
need of periodic vacations, if by that term we
mean a surcease from routine labor and substi-
tution of new scenes and thoughts. Properly
speaking, vacation should embrace change of
climate and variation of mental activity, rather
than complete cessation of labor, for it is
from changes that one procures that bodily
rest and cerebral stimulus which tend to re-
store healthy vigor. Thus we may find a
happy medium, between complete loafing and
constant work, fitted to the conditions that
affect most medical practitioners. The physi-
cian can take a rest from his usual routine of
labor and yet continue in touch with some of
his vital interests ; can do this perhaps better
than other workmen because there are so many
fields into which he may extend his studies
.further, to secure some interesting pictures of
foreign medical institutions. So, we took
along a “Filmo” and proceeded to record some
moving events.
In the beginning let us say that the often
heard excuse — “I can’t afford it” — is not
a sound reason for not taking an annual va-
cation. No man who is doing or wishes to do
high class professional work, and that should
apply to all physicians, can afford not to take
an occasional vacation. Few better invest-
ments exist, for the profits — renewal of en-
ergy and preservation of health — are certain
and immediate. Nor need the cash investment
be very large. True, travel is more expensive
now than in former times, just as the cost of
everything else has increased, but it is not
sufficiently high to be out of reach of the
average practicing physician provided he is
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
43
willing to travel on a moderate basis. Con-
sider, for instance, a European trip embracing
visits to great medical centers, whether for
clinical study or simple observation of insti-
tutions and passing events ; a vacation of 2
months duration can be financed on less than
$1000, with due allowance for living in first
class style; a single month of absence from
home, which covers 2 weeks on the ocean and
2 weeks abroad need not cost more than $600.
Of course, if one feels it necessary to travel
on the “ocean greyhounds” and to command
all the luxuries of the most fashionable liners,
more money can be expended ; but such a
course of action is by no means necessary to
a beneficial vacation. We have crossed the
Atlantic many times, and have tried all types
of boats, and experience has resulted in the
jumping off from Baltimore, in the County of
Cork, the southernmost point of Irish land, and
landing in Baltimore, Maryland. It happen-
ed that our ship landed us not far from the
northern extremity of Ireland, i.e. in Belfast,
so we had to traverse the entire length of the
country. We are not inclined to recommend
booking to Belfast unless you have some very
special reason for so doing. However, the
fact that we sailed around the northern coast
and close enough to procure a good view of the
land in the late afternoon and early evening
hours, compensated in some measure for the
discomforts of landing ; for the ship was an-
chored in the Irish sea and we were sent
ashore on a ferry-boat which consumed 2
hours passing up the bay and river, to put us
on the dock at 3 a. m. Sunday. It is far more
Fig. 2. Merrion Square. Specimens of doorways. American Consulate at right.
conviction that the greatest comfort and satis-
faction are obtained from the modern “cabin”
boats; such ships as the Samaria, Carmania or
Aurania, of the Cunard Line, and the De
Grasse or Lafayette, of the French Line,
offer all the necessary conveniences, perfect
comfort and excellent food, and are in some
respects preferable to the larger boats of the
same companies. The round trip can be made
on any of the boats named for $300 to $500,
according to size and location of room, and,
$10 per day is ample allowance for the time
to be spent on shore. Remember this when
preparing next year’s budget.
Having on previous voyages neglected Ire-
land, we determined to commence this time
with that country ; partly because we had a
desire for new sensations, and partly because
our maternal great-great-grandfather migrat-
ed from the Emerald Isle 150 years ago —
comfortable to enter Ireland by way of
Queenstown (Cobh), where facilities for
landing are much better.
Belfast has few attractions for the tourist;
in fact, we can think of none except that it con-
stitutes a good approach to the Giant’s Cause-
way, if you care to visit that freak of nature,
and that a side trip can be made by auto-bus
over a beautiful driveway which follows the
northeastern coastline for a considerable dis-
tance through County Antrim — a road running
along the edge of the cliffs much as our own
Hudson and Bergen County Boulevards fol-
low the course of the Hudson River along the
Palisades. Belfast is essentially a commer-
cial city, in the midst of a manufacturing
district, and except in the newer residential
portion has a drab appearance, though the
public park and suburban area redeem this to
some extent. The surrounding country is
44
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
charming, but that can be said of practically
every square mile of Ireland. From the first
glimpse of green behind the rocky coastline,
to the farewell view as we crossed to Wales,
we were conscious that the sobriquet— Em-
erald Isle— is most fittingly applied. No
green we have ever seen has been greener,
and no land we have yet seen offers anything
superior to the fertility of Ireland’s soil.
Everywhere, from north to south, from east
to west coast, the land is a rolling terrain, and
everywhere it is covered with a luscious growth
of plant life ; a sight to please anyone with a
countryman’s soul and a farmer’s eye.
Across the boundary line into the Irish
Free State and we entered Dublin. The
austere, sombre appearance of Belfast gave
way to the contrasting brighter and gayer
modern American cities ; and we were soon
to discover that in Ireland it is the general
custom. On our first car ride, we requested
the conductor to tell us when we should be
arriving at the point nearest to Dublin Castle.
After some little time, a gentleman leaned
across the aisle and said: “I heard you asking
for Dublin Castle. If you will get off at the
next corner, where the car will turn, walk
one square farther on this street, and then
turn to your left, you will be facing the
Castle.”i This was kindly intervention, for the
conductor would probably have forgotten us
because of other demands upon his time. On
other occasions, when asking for informa-
tion, people put themselves to considerable
trouble to render assistance. Such experiences
naturally led to conversations from which we
Fig. 3. Ruins of the Castle from whence came the Donohoes.
capital city of the recently organized Irish Re-
public. The fact w'as brought strikingly to our
attention by the coincidence of making our ad-
vent at the same time as the first French Am-
bassador to Ireland. An American Ambassa-
dor was installed some time ago, and while
watching the procession attendant upon the
French Ambassador’s reception, a kindly Irish
gentleman gave us an interesting discourse on
the local political situation, and, also, a lessoi
in Gaelic. And right here let us take advantage
of the opportunity to say that nowhere else
in the world have we met such uniform cour-
tesy as we found throughout Ireland. Our
first surprise came upon entering a crowded
street car, and observing that the passen-
gers moved to make room for us to sit down ;
such a delightful contrast to conditions in
gleaned valuable knowledge in addition to
what we had originally sought. Also, some
of these experiences were amusing as well as
interesting, for the Irish wit found abundant
chance for display.
Our Gaelic friend, while watching the am-
bassadorial parade and discussing various sub-
jects, drew for us a comparison with relation
to the Irish Free State's desire to take
life easily, saying: “We are not inclined to
rush and hurry, but prefer to take things
slowly. I had a friend, of about my own age,
who was always urging me to be more ener-
getic and do more business. He was not satis-
fied with business life in Dublin, and so he went
to Belfast and then to London, and he worked
hard, and he succeeded in making money and
building up a large business, but — he has been
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
45
living in a cemetery for 10 years, and I am
still hale and hearty.” And he was a remark-
ably well-preserved, patently successful man
considerably beyond the allotted three score
and ten years of age.
From the medical point of view our inter-
est in Dublin centered in Trinity College and
we spent most of our first day inspecting that
institution. Trinity is, as you probably know,
one of the world’s notable universities, and
dates from December 29, 1591, when it was
established by royal permission of Queen
Elizabeth. One of the chief points in esti-
mating the success of any form of govern-
ment is found in the attention paid to the sub-
ject of education, and we were interested to
learn the plans of the Irish Free State in this
respect. The Irish Times of Saturday, Aug-
(generally spoken of as Trinity College), is
of recent birth — only about 20 years old — and
has not yet attained any particular renown. It
is the present policy of the government to in-
sist upon the study of Gaelic in all the public
schools ; an order that seems to have greater
sentimental than practical value.
Trinity, with its 340 years of growth, has
become an institution of imposing appearance
and great national importance. The grounds
form a lovely park and the buildings are
pleasing from an architectural aspect, but the
Library is the center of attraction to anyone
at all interested in educational affairs. Like
Oxford and Cambridge, this University has
always received under British law a copy of
each' book published in the United Kingdom,
so that its library contains today more than
Fig. 4. Lake ICillarney at twilight.
ust'9, carried an explanation of the public
school system : compulsory school attendance
up to the age of 14, when a “Primary School
Leaving Certificate” may be obtained upon
satisfactory passage of an examination; sec-
ondary educational curriculum providing for
“Intermediate Certificates” after 2 years’ fur-
ther study (showing ability to take up ad-
vanced work or to enter technical schools) and
final “Leaving Certificate” at the close of an-
other 2-year period; and, “Honors Certi-
ficates” when pupils’ marks justify the award.
The leaving certificates have a definite value
inasmuch as they are accepted for matricula-
tion in the National University of Ireland, and
accepted with certain qualifications for en-
trance to Trinity College. The National Uni-
versity, which, by the way, must be dis-
tinguished from the University of Dublin
300,000 volumes of exceptional value for ref-
erence purposes. Then, claim is made locally
that the most valuable book in the world is
in the possession of this library ; that is, the
famous Book of Kells, a marvelous piece of
illuminated text of the gospels, the life work
of one monastic scribe in the eighth century.
This book is carefully preserved and is under
supervision of a special caretaker; each even-
ing it is placed inside a steel vault, and each
morning is opened at a new page and placed
in a glass case for the inspection of visitors
during the day — the opening at a different
page daily being designed to avoid too pro-
longed exposure of any given page to the ef-
fects of daylight.
Trinity is located in the very heart of the
city, the entrance being directly opposite the
old Parliament House, which is now used as
46
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Tan., 1D31
the head office of the National Bank of Ire-
land, and the chief buildings are ranged along
the 4 sides of an immense quad the center of
which constitutes a small park containing
many beautiful old trees. There is an inner
court, containing dormitory buildings, and at
the distant end of the outer quadrangle stands
the Medical School with its anatomic and
physiologic laboratories. In 1654 the College
of Physicians was established in connection
with Trinity College, and this connection is
still maintained in the choice of professors
for this medical school. The medical school
buildings are not very ancient but they were
undergoing reconstruction during the period
of our visit and the Sunday paper contained
the following interesting and witty news
item :
structure to the sister association buildings in
London. It might be mentioned, too, that the
British Medical Association has a separate
branch for Ireland, with a resident secretary
and office in Dublin ; but of our visit to that
institution we will speak later.
The region between Trinity and St. Ste-
phen's Green, embracing both Kildare Street
and Merrion Street, is rather fashionable and
contains many fine old houses that intrigued
us because of their beautiful front doors.
Perhaps the greatest mark of distinction about
the external appearance of an Irish home is
the portal of entrance; the architectural
beauty of the facade hangs particularly upon
this feature of the plans and many of these
houses have doorways of striking character.
The doors are made of fine woods, mahogany
Fig. 5. Typical Irish Village Market Day.
A Warm Time Cominc
“For some time now workmen have been busy
at the medical school, putting in new heating ap-
paratus. A new boiler of formidable proportions
was taken in through the front door — various walls
and windows having to be demolished to permit
its passage — and duly lowered into the depths. In
connection with the complicated arrangement of
engines of torsion and leverage, which were rig-
ged up to get the boiler into its new home, a
curious incident occurred. A steel cable stretched
some 6 ft. above the path smashed the windscreen
of the car of Dr. E. J. Watson. Had Dr. Watson
been decapitated, as he so nearly was, the Rugby
Club would also have lost its head; for he is its
President.”
We were interested also in visiting the very,
old homes of the Royal College of Physicians,
on Kildare Street, and the Royal College of
Surgeons, on St. Stephen’s Green, 2 of the fin-
est buildings in Ireland and quite similar in
predominating, and the woodwork, as well as
the brass knocker, is kept in a state of high
polish. Furthermore, they are protected from
the effects of inclement weather and the sun’s
heat by canvas covers that may be adjusted
as seems necessary. The fan-shaped tran-
soms, behind which in some instances one ob-
serves a marble statuette of some animal or
the bust of some distinguished man, add to
the interest as well as the beauty of these
entrances.
Leinster House, once the residence of Lord
Edward Fitzgerald, is now used as the meet-
ing place for the Irish Parliament. It is
flanked on either side by the National Library
and the National Museum ; the 3 buildings
forming 3 sides of a hollow square. Old
Dublin Castle, for many centuries the center
of political authority, is now being used as a
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
47
temporary home for the High Courts and as
offices for other divisions of the government
pending reconstruction of the buildings par-
tially destroyed during the revolution.
On the occasion of our visit to Dublin Cas-
tle. we had an unique experience. After hav-
ing been shown through most of the galleries
and some of the rooms that are not ordinarily
opened to visitors, our guide took us into the
court chamber where a case was being tried
and extended the courtesy of following the
proceedings so long as we might be interested.
The most impressive feature to us was the
manner in which the trial judge endeavored
to dispense justice ; a striking contrast to some
court scenes we have witnessed in this grand
and glorious United States. The case under
concerned.” Here was a judge ready to push
aside technicalities, in order to effect a full
measure of justice. Certainly a pleasing sight
in these days.
Our wish to photograph many interesting
and historic spots in Dublin was interfered
with by weather conditions. During the first
morning of our stay in the city we started out
with camera in hand but found a shower of
rain and returned to the hotel room for an
umbrella. As the elevator descended with us
for the second time within a few minutes we
apologized to the operator for not having
properly prepared ourselves at first, and then
asked whether it rained often in Dublin.
His answer was : “An umbrella is a useful
thing to have, sir, in Dublin, for you will
Pig. 6. View of Blarney Castle; indicating location of the famous charmed stone.
consideration concerned the disposal of prop-
erty left by some one’s Last Will and Testa-
ment, and the administrator, some fiduciary
company, was trying to force all of the lega-
tees to comply with orders of his own. The
attorney for the plaintiff had explained the
situation and requested an order of the court
to compel obedience. The judge listened at-
tentively and then said, in effect, something
like this: “Before calling upon the defense
to reply, I think I should say to you, sir, that
I realize you are trying to take advantage of
a technicality of the law, and that while you
may have a legal right so to do, I am not in-
clined to grant your request, for the simple
reason that such a decision would possibly
work great injustice to some of the parties
meet another shower about every second street
crossing.” His words proved to be quite true
not only for Dublin but for all of Ireland
during the 2 weeks we spent there. If we
can feel that it is a beautiful, charming coun-
try, in face of the continuous wet and cold
weather of this past summer, it must be some-
thing wonderful to see during a sunshiny
period. The Killarney lake region seemed to
us deserving of all that Tom Moore wrote
and that John McCormack sings about it;
veritably, “a little bit of heaven”. The nearest
comparable thing in America, in so far as we
can recall, is Lake George, but much as we
love this favorite spot, we are compelled to
admit that Killarney possesses even greater
charm. There is a bewitching beauty, a poetic
48
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
softness and delicacy, about Killarney that is
all its own, and we earnestly recommend it
to you for a short visit, or a prolonged so-
journ, according as you can afford the time ;
but do go there sometime during your life if
only for a fleeting glimpse. One can make, as
we did, a very delightful circular tour from
Dublin to Killarney, thence to Glengariff and
other points on the south coast, across to
Cork and up through Tipperary to the capi-
tol city again, and every mile of the way will
be enchanting.
In the cities, and in every town through
which we passed, generally close to the town
hall or to the church, we observed Public Dis-
pensaries, and our first thought was that these
its application to the 3 northern counties that
remain a part of Great Britain. This infor-
mation, with much more of interest, was ob-
tained through 2 very pleasant hours spent
with the Commissioner of Health of Dublin,
Dr. Russell, and the Secretary of the Irish
Section of the British Medical Association,
Dr. Hennessy. Dr. Russell had visited the
United States 2 years ago when the Rocke-
feller Institute conducted a tour of foreign
public health officers to study American meth-
ods, and Dr. Hennessy had practiced medicine
in England before and for a time after adop-
tion of the National Insurance Act, so we were
able to secure considerable authentic informa-
tion concerning medical conditions ; facts
Fig. 7 Kissing the Blarney Stone consists in hanging head downward into the opening
and placing the lips against the under surface of the basic stone in that portion
of the outer wall at the end of the iron bars. One has to hold firmly to
those bars, and it is advisable to have a friend hold the kisser’s feet,
to prevent an accidental fall resulting from dizziness.
were part of a national health insurance plan,
but upon inquiry we discovered that under
a very old law of the country free medical
service is provided for the poor, and each
district of a certain size has its own dis-
pensary, the attending physician being a paid,
part-time, official with the privilege of private
practice. The British Health Insurance Act
was meant to cover Ireland along with the
rest of the United Kingdom but in Ireland
it met with even less recognition than our
national prohibition law has been accorded in
some of the states ; in fact, throughout Ire-
land, it was simply ignored until 1928 when
action by the League of Nations resulted in
which will be utilized for discussion at a later
date. While we were in Dublin, however, the i
Irish Times published the following item:
Medical Benefits
The Irish Medical Committee has passed a reso-
lution drawing the attention of the Saorstat (Irish
Free State) Executive Council to the establishment
of a system of medical benefits in Northern Ire- 1
land, and suggesting steps be taken to provide
medical treatment for insured persons in the Free
State, preferably by the establishment of a na-
tional medical service on the terms suggested in
the Majority Report of the Committee of inquiry
on the National Health Insurance and Medical
Services.
(To be continued)
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
49
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J.
Entered at the post office at Orange, N. J.t as second-class matter
PUBLICATION COMMITTEE
HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J.
EDITOR:
HENRY O. REIK, M.D., F.A.C.S., Vermont Apartments, Atlantic City, N. J.
Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to
receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fact.
NOTE. — The transaction of business will be expedited, and prompt attention secured if:
All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to
The Editor, Atlantic City, N. J. _ .
All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements,
or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication
Committee, (address above), Newark, N. J.
THE PRESIDENT’S NEW YEAR
GREETING
The President of the Medical society of
New fersey takes pleasure in greeting the
membership in the New Year. He extends
his best wishes for a yrear filled wfith the joy
of work well done. He hopes the Great
Physician will shower blessings upon the mem-
bership and give them wisdom to cope with
the serious problems with which they are
faced.
To the Womans’ Auxiliary he pledges his
interest and support in its noble and unselfish
efforts to aid in promoting the aims and ob-
jects of the Medical Society of New Jersey
and to serve as an ally to that organization in
developing its program of health education
and public welfare.
George N. J. Sommer.
FRACTURES AND THE COMPENSA-
TION LAW
In the December Journal we published an
interesting discussion of the practical working
of the Workman’s Compensation Law, started
by Dr. Sherman’s paper on Eye Injuries. This
month we present an excellent corollary to
that review, in the papers by Drs. Adams and
Martin, on Fractures and Traumatic Surgery,
and the accompanying discussion. Taken to-
gether, these contributions pretty nearly cover
the complications and difficulties that inter-
fere with a smooth working of that law. You
will profit by reading the matter in its en-
tirety.
We may at the same time report that a spe-
cial subcommittee of the Welfare Committee
is now engaged in studying a plan for smooth-
ing out all the disagreements that so common-
ly arise between physicians and compensation
insurance companies.
A PROBLEM SOLVED. IOWA PLAN
OF SECURING PAYMENT FOR
SERVICE TO THE COMMUN-
ITY’S INDIGENT SICK
The Annual Conference of State Society
Secretaries and Editors, held at Chicago in
November, provided this year some discus-
sions of exceptional interest. President Som-
mer accompanied your regular representatives,
and in the Department of Communications
you will find a letter from him relating his
impressions. The Department of Lighthouse
Observations is also being utilized this month
for presentation of a summary of one of the
most important papers read at that confer-
ence ; a paper dealing with the relations of the
medical profession to the public, and especially
to the much talked about problem of state
medicine. It remains for us to direct your
attention to a paper presented by Dr. Robert
L. Parker, Secretary of the Iowa State Medi-
cal Society, under the title, “The Best Method
of Caring for the Indigent Sick”.
During a visit to one of our county societies
recently we heard a somewhat heated dis-
cussion concerning the relationship between
the local physicians and the Board of Free-
holders, with special reference, apparently, to
50
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
the disinclination of county authorities prop-
erly to compensate physicians for services ren-
dered to the indigent sick. Furthermore, a
situation was reported last month by the
Essex County Medical Society, indicating that
the Newark City authorities and the county
society are endeavoring to reach an agreement
whereby the city’s indigent sick will be prop-
erly cared for and the physicians will be paid
for services rendered. The Iowa plan for
providing adecjuate medical services to im-
poverished citizens, securing to physicians
payment for services rendered, and avoiding
disputes, seems to us peculiarly applicable to
some of our own county conditions.
Briefly stated, the Iowa plan provides that
the county medical society shall make a blanket
contract with the county authorities, under
which the latter will pay annually a fixed sum
to the society in return for proper medical
care, by members of the society, of all the in-
digent sick in that community. Such medical
attention is to be supplied upon orders of the
freeholders (or whatever may be the official
name of the county authority) ; and such ser-
vice is divided among members of the society
on as nearly an equable basis as possible. The
total annual payment goes into the society
treasury, to be disposed of as may be deter-
mined by the organization : members may be
paid out of this fund for services actually ren-
dered ; the unexpended balance may* be used
as the society sees fit ; or, members may con-
tribute their services without pay and permit
the society to utilize the entire fund for the
benefit, in some other form, of all its mem-
bers. Consonant with the last mentioned de-
vice, some of the Iowa counties have found
this money sufficient to relieve members of the
entire burden of dues to county, state and
national societies ; some propose using the
growing fund to establish an endowment;
some purchase insurance and indemnity poli-
cies for all members, on the group basis ; and
some use all or part of the fund for bringing
speakers from a distance, thus relieving the
program committee of a burden, or for con-
ducting post-graduate courses.
The income of the county society, from this
plan, varies in accord with the population of
the countv ; and the sick demand varies with
its percentage of indigent citizens. In Iowa,
the plan has been tried for a few years in 1 1
counties. The population ranged in these
counties from 16,000 to 63.000, and the con-
tractual payments ranged from $1600 to $12,-
600. In general, the obligation was to furnish
full medical service, including major surgery
when necessary, and medicines and supplies
except serums, antitoxins and salvarsans. It
will be noticed from the above figures that the
smallest county paid on the basis of 10c for
each member of the total population, while the
larger county paid upon the basis of 20c. The
total population of the 11 counties being
316,201, and the total amount of money paid
into the 11 county medical societies $36,530,
you will observe that the average payment was
upon the basis of a trifle over 1 lc per citizen.
The membership of the smallest county so-
ciety numbered 10; of the largest county, 86;
the average being 36. As the total registered
membership was 370, and the total fund $36,-
530, the average allotment for each physician
might have been a little less than $100.
In some of the counties the work was per-
formed by assigning patients to the nearest
physician ; in some instances arrangements were
made whereby members of the county society
rotated in service; in some counties the pa-
tient was permitted freely to select his own
physician from the county society member-
ship.
As indicated, the plan worked admirably in
so far as it has been tried in the state of Iowa.
It has resulted in physicians being paid for
services rendered to the indigent sick* just as
other services and supplies to such citizens
are paid for by the community ; thus eliminat-
ing the injustice of placing upon physicians
alone the burden of caring for the sick poor.
It has further resulted in a general satisfac-
tion of the community with its physicians
through this supplying of effective medical
service to the needy, and it has also resulted
in the removal of friction between physicians
and local boards of supervisors and social
workers. Finally, it has served to provide
the county society with much needed funds to
carry on scientific or educational work.
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
51
Economics
THE OPEN HOSPITAL
William H. Ross, M.D.,
President of the New York State Medical Society,
Brentwood, Long Island, N. Y.
There is no other practical way of bridg-
ing the gap between the time of a doctor's
graduation in medicine and the present day
knowledge, than by experience in a hospital.
Practically, this is possible for all of the pro-
fession in an open hospital. Much has been
written about the merits of an open or closed
hospital but considering the educational in-
fluences on the profession, an open hospital is
of greater community value. In no other way
can the profession be kept in the proper state
of education regarding modern medicine than
by continuous education in its own environ-
ment. It is not the primary obligation of
hospitals to undertake to make specialists and
it is the obligation to train the 80% of the
profession who are general practitioners and
who attend to that percentage of care of dis-
ease.
If those who manage hospitals do not make
them available in some way to the entire pro-
fession for practice therein, so as to benefit
by the education that flows from them, we
are not protecting the public, by making good
doctors, from that ever present tendency of
the human mind to credulity and the unusual
nor are we developing availability of the
science of prevention and cure of disease — an
ideal that came to the front in the initial meet-
ing, in 1807, of the Medical Society of New
York State when it offered a prize greater in
value than its then entire financial resources
for the best method of prevention and cure of
Typhus Mitior.
I believe that with the 1,000,000 hospital
beds in 9000 hospitals and the increase of
127% in hospital facilities in the last 20
years, the time has come when every doc-
tor should have a hospital connection un-
der some plan. A hospital does much for a
community. It sets up an advanced standard
of practice. In addition to making better doc-
tors it becomes a real source of education to
the public and steadily breaks down medical
ignorance, the greatest foe of public health
advance.
Medicine has done much for human wel-
fare and for civilization, and the education
that flows from a modern hospital can con-
tinue this and make it the greatest modern
factor in advancing these age-old functions of
the profession of medicine. In New York
City and its metropolitan area, the educational
advantage offered physicians seems consider-
able when we realize that 51% of doctors
have hospital or out-patient service, 16% of
the remaining are either retired or engaged
in other phases of medical work, leaving 34%
who are without institutional appointment,
but since there are in New York City 10,877
physicians, 3698 are by the present system of
hospital service largely deprived of the oppor-
tunity of continued education. The only im-
portant difference that I know of in the medi-
cal situation in New York City is that there
is 1 physician for 550 people and in the
rest of the state the average is 1 for 793
people. You may draw your own inferences
regarding professional attitudes toward clinics,
health centers, and the economic situation, and
efforts to improve it.
The question arises — is organized medicine
meeting its obligation to provide the best kind
of physicians that it can ; and right here I
would like to say that which I have said on
several occasions this year, that it is time for
organized medicine to self-appraise its own
organization and offer proposals for the solu-
tion of problems that government has taken
on in 23 other countries, if the profession is
going to avert more state medicine.
The rural hospitals of New York State are
generally open hospitals and their standards
of practice are good. Human nature is about
the same in rural as in urban sections. If an
open hospital brings about arising of the level
of professional ability of practicing physicians
and prevents a loss of professional prestige,
and gives the patient the right to select his
own physician, insuring personal interest and
responsibility' for his welfare, then it is worth
trying in cities and the few remaining places
in the country under the guidance of medical
statesmanship with rules, regulations, and
penalties for enforcement of standards to see
if it does not work out as well as it now works
in many small communities in New York
State doing work equal in results to the av-
erage city hospital. My experience in hos-
pital organizations makes me believe that the
essential control is compulsory staff confer-
ences to review the catastrophies and to record
the story of diagnosis and treatment, so that a
strange doctor reading it would understand
the case, and, then to file the record so as to
be easily accessible for study.
Sometimes I think that perhaps our own
profession is dividing itself into 2 classes —
one the conservative, guided by tradition ; the
other the liberal, interested in human progress.
5.2
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE\
Jan., 1931
Collateral Reading
THE FUTURE OF FREUD
The Structure and Meaning of
Psycho-analysis
By William Healy, Augusta F. Bronner
and Anna Mae Bowers
{Reviewed by Joseph Jastrow in Saturday Review
of Literature, June 28, 1930.)
Despite the increasing numbers to whom
the ideas underlying psycho-analysis have be-
come familiar, the recent restatement of
“Freud” by Freud is relatively unknown. His
disciples have , carried on a campaign of ex-
position of the clinical phases and their bear-
ing on life problems and the interpretation
and organization of human motives. The di-
vergent views of Jung and Adler, of Adler
notably, continued the same emphasis with
more liberal interpretations. Yet through it
all the starred feature is the origin of the
neurotic trends and the technic for their con-
trol.
Dr. Freud shows the characteristic tendency,
as thinkers approach three-score-and-ten, to
lose interest in the collection of data and focus
upon the fundamentals which now, as of old.
implies a philosophy. This is equally true of
William James and Wilhelm Wundt, two
other master minds. Freud’s interest in clin-
ical psycho-analysis has given way to its
theoretic formulation, which in truth is not
“psycho-anal ysis’Jat all ; Freud calls it “meta-
psychology”, which supplies in the apt title
of Dr. Healy ’s notable book “the structure
and meaning of psycho-analysis”.
A correctly perspective view of the Freu-
dian psychology is not likely to arise in the
clinical camp of Freudians. They are too
closely absorbed in the intricate psycho-analyz-
ing of “cases,” whose complexity they tend
to exaggerate, and whose diagnosis they coerce
into conformity with accepted doctrines.
There is in all a marked cultist streak which
is not conducive to reflective clarity or ob-
jective sanity.
The contribution of Dr. Healy, Dr. Bron-
ner, and Miss Bowers may be accepted as
a long anticipated recognition of the develop-
ment of Freud’s views as a theory of psychic
motivation. Dr. Healy is not a psycho-analy-
tic practitioner; he holds no brief for any
school or cult. He utilizes the psycho-analytic
approach in the handling of personality and be-
havior problems of a far more varied and
directive character than appear in a neuro-
logic clientele seeking relief from oppressive
conflicts. He is a broader type of clinician;
and it is fortunate that he has included among
his interests that of setting the Freudian
house in order.
While I expected such a book to appear in
due course, it was my further anticipation
that it would be devoted to the clinical phase
of psycho-analysis. This is still an urgent de-
sideratum and would form volume 1 of the
magnum opus of which Dr. llealy and his
associates have given us volume 2. The
method adopted in this book is well adapted
to the purpose in hand. It consists of a large-
type text on the left hand pages, stating
Freud’s own formulations, with a commen-
tary on the right- hand pages in smaller type,
setting forth the variant views of followers
and dissenters — a psycho-analytic Talmud. It
requires a close knowledge of the subject to
follow this exposition, a far more sustained
interest than even the well versed student of
psychology is likely to command. lo the
serious student of the subject it is an indis-
pensable guide.
So much for the right hand text indicating
the purpose and temper of the volume; and
now for my left hand comment which, I fear,
will in some circles be regarded as a left hand-
ed compliment. For the fundamental ques-
tion that readers of reviews of books-to-be-
read will ask, relates not quite to the structure
or the meaning, but to the significance and
value, and the ever persistent truth of it all.
Freud is weak, whether by temperament or
training in the architectural sense; he erected
his edifice as a series of facades and additions,
with a ground-plan supplied as he built. Now,
retrospectively, he makes good his deficit, yet
never with the skill of Dr. Healy’s penetrat-
ing pragmatic gift. The “cardinal formula-
tions” are libido, cathexis, polarities, ambival-
ence, the unconscious, preconscious, and con-
scious, the “id”, the ego, and the super-ego,
the fundamental principles; pleasure and
reality, Nirvana and compulsion, the Eros or
life instinct, the death or destructive instinct.
All of these have their developmental stages ;
a life is a genesis and a growth. They have
their constitutional patterns strongly influ-
enced by early experience. They disclose me-
chanisms, here better called dynamisms ;
and they end in character and personality, and
there find their consummation and justifica-
tion. Therapy is but an application and ap-
pears in the concluding chapter alone, how-
ever closely theory follows, the clues of clini-
cal findings.
This bare enumeration and its unintelligi-
bilitv until elucidated, make it clear that the
Freudian metapsychology is a new science, or
shall we say speculation? It requires a new
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
53
vocabulary, a new approach, a new set of
concepts. This story of the lify of the mind
is completely different from ithat of the stand-
ard psychologic versions of whatever origin
that occupy academically and practically the
great body of contemporary psychologists. If
Freud holds the clue, they are pursuing false
trails.
Has Freud made good? is the question.
For what all this means for the understanding
or management of a human life can but be
hinted at in a review. If lives and personalities
are but Freudian exhibits, then for the great
majority life is lived with a minimum of un-
derstanding. It means that we are fearfully
and wonderfully, sexualized, not merely the
lower centers of our protozoic past, now sur-
viving as the “id”, but equally the higher cere-
bral areas where ego rules' and the super-ego
soars, starting, like an airplane, with wheels
on earth, but winging its way to the altitudes
of human aspiration. We are victims all of
the Oedipus fate and the emasculating dread
called the castration complex. Our urges-
hover between life and death; we are victims
of birth traumas and sex shocks. Our genital
origin imposes, a genital consciousness that
never leaves us, and all we can do to live the
life industrial, social, or intellectual is to con-
vert and sublimate and transfer and symbolize
dn'd project and rationalize arid idealize the
original and persistent libido. Sex thou art,
to sex returnest, was first (and last) spoken
•of the soul.
Is this really the truth of life? Is there no
alternative except that of being glandular
marionettes or Freudian fobots of most fear-
ful and wonderful construction? Must we
ever appease our “id”, consult our sub- and
pre-conscious, make terms with ego and
super-ego, before we can hope to understand
ourselves or meet our' fellow men? Is a nor-
mal man realty made in the image of a Freu-
dian neurosis? Will the momentous decision
of the future be Freud or anti-Freud?
When we are told that the fear of small
Tying or crawling insects derives from the
tear of the father who also makes a sudden
appearance and excites the idea of getting rid
of him; that smoking derives from a fixation
on the nipple, and eating sweets from the
mother’s milk; that “later interests in paint-
ing, sculpture, cooking, metal molding, and
carpentry are believed to be traceable to cop-
fophilic pleasure in smearing and molding” ;
that characters . divide according to anal and
oral persistences, we seem to be justified in
consigning the entire system that sponsors
such conclusions to the nearest wastepipe, and
then ask wherein “psyching” is more scientific
than other pretentious and marketable sys-
tems of reading character.
For there is the crux of the Freudian con-
troversy.
Viewed in one aspect it seems to offer a
penetrating illumination into the motives of
life; viewed in another, it becomes a gro-
tesque and degrading caricature. What is
wrong : the structure or the details, the archi-
tecture or the plans and specifications ? Im-
portant as it is to see the movement through,
will the verdict of science declare it all in-
genious futility and error, or a revelation of
an unpleasant but vdrolesome truth? The re-
flection can hardly be avoided: if this is Freud,
is Freud -worth it?
Dr. Healv has furnished the protocol for
a fair trial, and has done so in terms of
Freud’s, matures! convictions. Among the
recent contributions of Freud is a temperate
but definite essay, “The Future of an Illusion",
describing the fate of religion as it emerges
from the psycho-analytic mill. Will some
future critic consider Freudianism under the
same title?
Medical Ethics
LOWERING OF THE STANDARD
OF ETHICS
]ohn Hammond Bradshaw, M.D., F.A.C.S.,
Orange, New Jersey
“We have, lived from the time when public ad-
vertising of doctors was considered an ethical sin;
and into the time when the most , flagrant adver-
tising of very prominent doctors in the lay press
has been considered a remarkably virtuous per-
formance.”— Parker Syms.
I quote the above rather ironic words of a
celebrated surgeon, the son of a most cele-
brated father, which were recently received in
a personal communication, and I give the pass-
age with the kind permission of the author.
Now, allowing for all altered conditions of
this changing world, is the profession advanc-
ing or retreating?
The standard of so many things is under-
going transition. Doctors are not the only
ones on whom the spot-light can be thrown.
Many of the practices of the present day,
when viewed by the light of years ago, might
not only bring ostracism to the perpetrators
thereof,, but could even land these individuals
behind bars. (But, ialas, the bars of those
days were different from the bars of today!)
Even the Church is having the spot-light
of criticism thrown in its direction.. And this
is not entirely the fault of the laity!
54
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
Business by its very nature and require-
ments is always changing its standards. An
optimist naturally thinks things are always
like Cone's little rhyme. Unfortunately, the
other persuasions are vocal.
If the writer should begin to write on the
ethics of sex relationship, he might get him-
self in deep waters, but here there are also
many shallows — also many rocks!
It is even a debatable question if the lower-
ing of the present strict ethical standard of
National Prohibition would not elevate the
righteous cause of Temperance (spelled, with
intent, with a big T).
After all, “to err is human’’ ! A straight
thinker is, generally speaking, also a “straight
shooter”.
What is the matter with the Golden Rule?
Esthetics
MUSIC IN RELATION TO ART AND
LIFE
PADEREWSKI’S PESSIMISM
(From the Literary Digest, Nov. 15, 1930.)
Paderewski sat on the edge of his chair as
if playing the piano.
The great shock of auburn hair, made
famous in Burne-Jones’ drawing, is now thin
and silvered.
“His high but sloping forehead is his
most characteristic feature, and, dome-like, it
dominates the remainder of his head, and in
comparison with the lower part of his face
seems small.”
“There is nothing of the far-away musician
about him.”
These bits of personal character, observed
by S. J. Woolf, during his interview with
Paderewski for the New York World, com-
port with the thoughtfulness and vigor of the
musician’s talk about the situation where our
mechanistic age has placed all the arts, not
simply music.
Finding music is only a little behind the
trend followed by pictorial art, he asserts that
“art has been on an orgy”. Thus:
Some few years ago it went wild for color.
Line was forgotten in mad desire for vivid hues.
Today music is still in the state that painting
was in some years back.
Color is the god before which all modern com-
posers are worshiping, but they forget there are
other gods than that. They have blinded their
eyes, if I may so express it, to the beauty of the
simple lines of the classicist, and endeavor by ef-
fects of color to attain beauty without line.
Light and shadow and the glow of color are
wonderful, but they must have outlines to bound
them, otherwise they are formless masses. And
then, too, while I have been speaking of painting
and music in similar terms, after all color is not
music.
Next he was asked what he thought was
back of these tendencies in the arts, and Pad-
erewski, who was once Premier of Poland,
showed he has reverted to the artist, when he
said :
We are living in a strange age.
Economics and inventions and discoveries have
held the public attention for some years.
I do not underestimate the value of these things.
They, may make for physical comforts, but with
them they bring attendant evils that kill creative
genius in art. For genius is a tender plant which
will not thrive in all soils or surroundings, and the
quiet and peace that are essential to it have been
driven out by the mad haste and constant desire
for change and challenge that mark this era.
Individuality and originality are being killed by
the increasing necessity, I might almost call it, for
collectivism.
The day of the lonely craftsman has passed. One
man rarely produces any finished product today.
It is the result of many hands, and while better
automobiles may perhaps be produced in this way,
surely better poems or paintings or sonatas can not.
And it is this spirit which is pervading everything.
For great art, though it is the creation of one
man, is the product and the result of the time in
which he lives.
Bach could not have written his works in a
sky-scrapper any more than Michelangelo could
have decorated one of the modern temples of in-
dustry.
Men are not happy today, he thinks, and,
throughout the world, in politics as well as in
all the arts, is “a constant desire to get away
from existing conditions". He continues:
In art there is a striving for originality. Men
are endeavoring to create something new.
Nothing new was ever created consciously. True
originality has its foundations in the soul, not
in the mind, and when there is an effort to create
something different, it is usually a failure. Beetho-
ven or Schumann or Chopin did not try to be
original. They were original.
However, this craving for originality, this desire
to get away from old forms, this pulling down of
the old-time gods, is typical of this period of the
world’s history.
Men feel the same dissatisfaction in regard to
politics.
Throughout the world there is an undercurrent
of unrest.
For years the so-called parliamentary system
in government had been looked upon as a panacea
for all ills. It was felt that when the man in the
street was represented in a legislative body, then
that man had something to do with the making
of the laws and management of his country.
But ideas in regard to this are changing.
People are beginning to feel that this system is
not altogether what it promised. Indeed, it has
been my experience that in most bodies of this
kind a tremendous amount of time is wasted in
useless and futile talk.
Jan., 1931
55
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Hours are used up in listening' to speeches of
no import or value. In times of economic distress
long discussions in parliaments only irritate.
A hungry man’s appetite is not appeased by
words. What he wants is food. And when he
sees that the words do not give him food, he be-
comes dissatisfied with that system of represen-
tation which does not provide him with necessities,
let alone comforts.
It is this spirit of dissatisfaction with things
as they are that has caused both the artistic and
political restlessness throughout the world today.
In Lighter Vein
Fact-Finding Stuff
A committee of 5 usually consists of the man
who does the work, 3 others to pat him on
the back, and 1 to bring in a minority report. —
Royal Arcanum Bulletin.
Banking On Wiley’s Nerves
Jinks — “My wife thought she heard burglars
last night, and I went straight downstairs to in-
vestigate.”
Binks — “Gosh, how could you be so positive she
was mistaken?” — Chicago News.
On the Sunny Side of the Grass
“My brother is working with 5000 men under
him.”
“Where?”
“Mowing lawns in a cemetery.” — Log.
Concern advertises the perfect bridge lamp.
Must be light enough to see by and too heavy to
throw. — Dallas News.
Scientists have achieved some wonderful re-
sults, and maybe in time one of them will succeed
in producing a cigarette the ashes of which will
match the color of the rug. — Louisville Times.
Answered at Last
She (in poetic mood) — “What are the wild waves
saying?”
He — “Sounds like ’splash.’ ” — Panther.
It now appears that the coffee situation is the
chief cause for the revolution in Brazil. We’ve
tasted coffee like that, too. — Judge.
An insane-hospital up in New Jersey has in-
stalled a miniature golf course for use of its pa-
tients. Try to laugh that off. — Jackson News.
As Good as a Lip-stick
Martha, aged 4%, had been ill. Protruding her
tongue, she asked : “Mother, how does my tongue
look?”
“Oh, it’s all coated white.”
“You buy me a red lollypop and I’ll fix it.”
In Dire Need of Strength
The following message, pencilled on a scrap of
wrapping paper, was recently delivered to a
physician, member of this society:
“Pleas give this boy strong medcin as I didn’t
adminstrate reglar for 2 months so send some-
thing strong.”
Lighthouse Observations
THE PUBLIC RELATIONS COMMITTEE
It has been our custom to carry in this de-
partment a resum.6 of recent scientific develop-
ments in regard to some particular disease prob-
lem but this month we are devoting the space to
a problem of equally great concern to the profes-
sion: i.e., to the best means of dealing with some
problems that affect the health of the medical
profession itself. At the moment there is so much
discussion of economic problems, general and spe-
cific, that we cannot find sufficient space for publi-
cation of all that seems pertinent to our needs or
relevant to our daily occupations. In consequence,
we shall present for your information, through use
of this column, an, abstract of views expressed at- the
recent annual Conference of State Society Secre-
taries and Editors, held under the auspices of the
American Medical Association, by Dr. William H.
Ross, President of the Medical Society of New York
State. The meeting in Chicago this year, attended
by the President of the Medical Society of New
Jersey, Dr. George N. J. Sommer, as well as by
your Secretary and Editor, Drs. Morrison and
Reik, was an exceptionally interesting event; as
you may learn from a special letter in this issue
of the Journal, wherein President Sommer records
his impressions.
At each of these annual meetings, the Secre-
taries of all the State Medical Societies — and such
officers are in closer touch with and make per-
haps the best possible representatives of gener-
alized state professional opinion— confer upon one
‘ or more vitally important organization problems.
On the recent occasion. Dr. Ross presented an
elaborate paper upon the subject of “The Public
Relations Committee” as developed in the medical
society of his state during the past 3 years. We
may be permitted to say at this point that the
functions of that committee are embraced, in New
Jersey, in the program of our Welfare Commit-
tee; in other words, we have the same thing un-
der a different name. In New Jersey, too, during
the last 2 years, practically every county medical
society has provided for a local welfare, or public
relations, committee of its own, to function locally
and to cooperate with the similar state society
committee. So, we have, already set up, the ma-
chinery for consideration of and action upon such
problems as Dr. Ross , was discussing.
Dr. Ross’ paper will in due time be published in
full in the American Medical Association Bulletin,
so we shall attempt here to present only a con-
densed report upon the more important features
of his address, as follows:
There is an economic disturbance in the medical
profession greater even than the general economic
disturbance in industry. The medical profession
has for some time blamed health organizations,
and even departments of government, for public
health activities, on the ground that they have in-
terfered with the private practice of medicine.
The profession has seemed to believe that inter-
ference with private practice is solely due to ac-
tivities of these agencies, and has seemed to for-
get that medical research and discoveries, to-
gether with changed social conditions and in-
crease in public knowledge, are the real causes
of such activities. Times are changing. The gen-
eral public, has become interested, and industry
and civic organizations are at work, in response to
public demand and supported by public opinion,
trying to advance health service with a view to
56
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., J931
saving as much as possible of the $100,000,000 an-
nual wastage through preventable illness. There
is an oncoming tide of public sentiment for the
advancement of public health, with the object of
limiting illness and lengthening life, and providing
adequate medical care in sickness;-. No one could
sit through , the recent. 4-day meeting of the Ameri-
can Public Health Association, with its 10 sections
going on concurrently, its 16S speakers listed, and
the largest number of practicing physicians ever
in attendance, without realizing that times are
indeed . changing. The effort of organized medicine
to meet its own professional problems has up to
The present time been along , the line of creating
committees and bureaus for study of economic
problems and in argument against the health ef-
forts of various agencies and the paternalistic
tendencies of government. Organized medicine
has not undertaken an impartial appraisal of its
own organization to see whether its own public
medical relationships are such as to make it most
efficient in the distribution of preventive measures
and provision for medical care.
. Organized medicine must realize that the day
of isolation is over and that it must go through
the throes of adjustment to new conditions and
prepare to go along with the irresistible force of
public opinion. Our Public Relations Committee
in 'New York has during the1 past 2 years ar-
rived at a more comprehensive conception of . the
obligations resting upon the medical profession —
to render satisfactory public service as well as to
attend to its own private business. We recognize
that scientific medicine has develojied much faster
and traveled further than has the application of
scientific discoveries to the limiting of unnecessary
illness and the provision for adequate care of all
classes of sick people. This committee believes that
it, is, proper to secure aid from other sources, when
funds are not available from general taxation, for
administrative organization of mass or semi-mass
health service, and for health education; that the
profession is responsible for guidance of all efforts
to advance preventive medicine; and that the pro-,
fession should be the major factor in proposals
for solution of the great problem of adequate medi-
cal care.
Organized medicine will not overcome its diffi-
culties until it has made a proper self-appraisal
and determined whether it is meeting all of its
obligations to render public service. If it does not
meet these obligations, some other agency will;
and possibly in a manner that will be unsatisfac-
tory to the profession. The organized profession
of Great Britain has just made a proposal for ex-
tension of the National Health Insurance Act; a
proposal that might better have been made 20
years ago, although it is to the credit of the Brit-
ish Medical Association that it is now properly
meeting the situation. There is a lesson in this
for the medical profession of America. Will we
heecl it?
Medicine has come to have a public character ;
knowledge of what can be had in the way of
health service is rapidly expanding; the broad-
casting of unsolved health and medical problems
is increasing. The social trends of the time ir-
resistibly insist upon better health service; as is
reflected in public welfare laws, old age pensions,
etc. The profession is confronted by a new state
of affairs.
Heretofore, medicine lias spent its effort largely
in studying the effects of public health service
upon its own material rewards and has given a
minimum of consideration to the causes under-
lying social changes. We might well consider
some of these social changes: the increased pur-
chasing power of the public, due to better wages-
and shorter hours of labor; increased education;
tripling of the per capita wealth during the past
25 years; the increase in man productivity by 40%
within 12 years; the present mechanized state of,,
industry, resulting in unemployment because of
the lessened need for men.
Emerson tells us that society is always taken
by surprise at any new example of common sense.
Let us see if we can apply common sense to our
problems. There are 2 methods of procedure
open to the medical profession. One is to fight
public opinion and retreat as slowly as we can;
you can find examples of that expressed quite fre-
quently in medical meetings. The other is to ac-
cept the practical philosophy of self-appraisal, and
if the result of such self-examination warrants it,
to make proposals for meeting public health needs
by the prevention of illness and the jn’ovision for
proper care of the people when sickness combs.
The second method may be successfully followed
if our relationships be changed so as to cooperate
with other agencies under the expert guidance of
the medical profession. Are we equal to this
responsibility?
The Public Relations Committee of the- New
York State Society, as a preliminary step, under-
took to have organized in every county society a
Public Relations Committee. Then, it undertook
to have each county committee make a survey of
the health activities of the county and the relation
of the local profession to them. If the principle
of conference between the various health agencies
was not in use in reaching conclusions, and if
there was not a cooperative relationship, then the
State Committee undertook to bring about such a
conference with the object of cooperation on the
fundamental basis that the medical profession was
the only body that could give expert guidance to
methods of distribution of health services and
that it was willing to be consulted.
Notwithstanding the almost complete transfor-
mation of medicine within the recollection of many
of us, because of laboratory aids and the use of
instruments of precision in diagnosis and treat-
ment. there may come another revolution in medi-
cal practice, as it has come in the past, as the re-
sult of great social needs, and who knows that
it is not beginning. We may be nearer than we
know to such things as unlimited old age pensions,
provision for adequate medical care by the state,
and the inclusion of sickness benefit in Workmen’s
Compensation and compulsory health insurance
laws as in other countries. It should make us
think.
The work that the Public Relations Committee
undertakes to do is to establish by conference a
conclusion as to plan and then a cooperative re-
lationship between official and unofficial health
agencies and the medical profession. It under-
takes to arouse medical interest in present day
social trends and the need of providing plans for
the distribution of preventive service, i. e. the
establishment of a county health department with
a full-time and trained personnel. Another is the
support of the work of Parent-Teacher Associa-
tions and the value of the family physician in pre-
school work. Another is the proper relation of the
medical profession to the movement on the part
of the state to aid in the establishment of county
hospitals so that the entire profession may have
the educational opportunity arising from service
in a hospital and in formulating rules and regu-
lations to control standards of practice.
The Public Relations Committee undertakes to
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
57
adjust differences of opinion between the medical
profession and the health activities of other or-
ganizations by use of the principle of conference
while the proposals are in the formative stage. It
undertakes to visualize the medical future; to see
as far as possible what is ahead in medicine and
plan such relationships as are necessary for medi-
cal leadership. The medical profession can never
cure the ills that it complains of by fighting the
present social trends. It can no longer afford, in
more senses than one, to hold a hostile attitude to-
ward any health agency supported by public
opinion. It will suffer if it does not have a re-
ceptive rather than a hostile attitude.
I have been a part of a movement in my county
medical society that has resulted in as desirable a
relationship of the profession and health agencies
as one could conceive of — a movement that has
given the profession leadership with the support
of lay organizations. A county medical society
that does not modernize its relationship into har-
mony wtih new conditions is not meeting its pro-
fessional obligations nor laying a foundation to
prevent economic disturbance of the private prac-
tice of medicine.
No amount of resistance to the present social
trends will make any final difference. Continuation
of present methods to cure our ills will amount to
nothing. To consider medicine under seige, and
the tendencies of government as paternalistic, will
avail nothing; but self-appraisal of ourselves and
proposals from the organized profession regarding
medical problems will succeed and will put the
profession of medicine in the position that it
should be in and the position that public opinion
expects it to occupy.
Public Relations
SURGEONS REDUCE FEES
(From N. Y. Times, Nov. 18, 1930.)
A plan to reduce the cost of medical attention
for the so-called white-collar workers, under which
2 hospitals will reduce their rates and prominent
physicians and surgeons will give their services
at decreased 'fees, was announced last night at a
dinner in the Hotel Commodore.
The hospitals are the Park West at 170 West
Seventy-sixth Street and the Park East at Park
Avenue and Eighty-third Street, both built origin-
ally by the same stock company to care for wealthy
patients. The plan was described to 200 members
of the staff of the 2 institutions by Thomas F.
Dawkins, executive manager of both hospitals.
If the reduced rate program proves successful,
both institutions will be turned over to the doctors
and nurses of their staffs for operation as co-
operative enterprises, according to Mr. Dawkins.
Although the plan was not announced as in any
way connected with the recent statements of
Health Commissioner Wynne, that doctors are
faced with the alternatives of lower fees or State
Medicine, it agrees with Dr. Wynne in its em-
phasis on the need for placing hospital care with-
in reach of persons with moderate incomes.
The Park West Hospital, opened in 1926, has
75 beds and represents an investment of $750,000.
The Park East Hospital has 130 beds. It was
opened in September 1928, at a cost of approxi-
mately $1,000,000.
Since these institutions were designed at first
only to serve wealthy patients, the cost for a
room was fixed at from $13 to $40 a day, Mr.
Dawkins said. Under the new plan it will be pos-
sible to obtain a room for $6.50 a day. For those
who desire better accommodations there will be a
maximum of $30 a day.
The practitioners who have already agreed to
reduce their fees include some of the best known
medical men in the city. The practice of basing
fees for operations on the patient’s apparent ability
to pay would be curtailed to a great extent, Mr.
Dawkins indicated.
Medical men connected with these institutions
include Dr. Thomas Darlington, former health
commissioner, who is on the advisory board, and
Dr. Howard M. Hayes, president of the board of
both institutions.
INFANT MORTALITY LOWEST IN HISTORY
(Newark Evening News, Oct. 24, 1930.)
New Jersey’s infant mortality rate for 1929 is
the lowest ever recorded for this state, according
to statistics of the bureau of census and division
of vital statistics of the United States Department
of Commerce. The rate was 60 deaths under 1
year of age per 1000 births. New Jersey is 1 of
11 states whose rates are lower than at any time
since their admission to the registration area.
The infant mortality rate throughout the regis-
tered area, which comprises 46 states and the Dis-
trict of Columbia, is 68 per 1000, the second lowest
since the establishment of the birth registration
area in 1915. For the sixth consecutive year, Ore-
gon leads the states with the lowest rate, 48.
While the infant mortality rate throughout the
country was lower than usual last year, statistics
show that the birth rate for 1929 was 18.9, the
lowest for any year since establishment of the
birth registration area. Oregon had the lowest
rate, 14.1, of any state. New Jersey’s rate was
17.2.
PENDING LEGISLATION ON ABELL
COMMISSION REPORT
In the Welfare Committee Minutes (page 65)
you will find a review of the 3 Bills now under
consideration in the Senate of the General Assem-
bly, and will note the decision to oppose passage
of those Acts. It seemed necessary to oppose S.
262 and S. 304 in toto because of their glaring
defects. Inasmuch as the medical profession is
not opposed to a proper budget system honestly
constructed and applied alike to all governmental
departments and boards, without discrimination,
it was suggested that these Bills could be made
acceptable by amendment, and the changes pro-
posed were designed: to clarify the question of
authority; to guarantee that the boards would be
allowed appropriations as large at least as their
own receipts — to carry on law enforcement; to
place the new “bureau” under the Board of
Regents instead of a state officer whose appoint-
ment and tenure of office are subject to political
control; and, to “cover in” the lawyers and realtors
along with other examining and licensing boards.
These points are all excellently well expressed
and approved by an editorial in the Camden
Courier-Post of December 16, as follows:
Bill 304 Carries the Spirit of Reform but not
the Substance!
New Jersey has 14 separate professional boards.
Each has its own secretary, maintains its own in-
specting staff, operates its own office and collects
and disburses its own funds.
58
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
Bill 304, sponsored by the Abell Commission,
would consolidate 12 of these boards under a
Bureau of Professional Registration. Hearing on
that measure takes place today, and vigorous pro-
tests are being lodged against it, especially by the
medical profession.
The principle embodied in this bill is one for
which this newspaper has long stood — economy in
state administration through consolidation of ac-
tivities and centralized financing. No private
business permits each of its departments to handle
its own financial affairs and, to all effects, operate
as an independent concern.
There are, however, serious defects in Bill 304.
The medical profession, not without reason, asks
why the legal profession should be exempted from
the measure along with the State Real Estate
Board? If it is good business to consolidate 12 of
the 14 State boards should it not be even better
business to consolidate the whole 14?
Lawyers, however, drew up the measure. And
by exempting themselves they expressed exactly
the same opposition to the bill that the physicians
and other protesters are to make at today’s hear-
ing. That is, they don’t object to the principle of
this bill — only they don’t want to be subject to it.
******
More serious than that seeming discrimination,
however, is the fact that Bill 304 will tend to limit
the professional authority of the various boards,
although they will still be continued in existence.
There is a justification for the fears of physi-
cians that the proposal to place all the boards
under the authority of the Commissioner of Edu-
cation— a political appointee — will tend to bring
politics into the various boards and lower their
standards.
Especially is this important where the boards
concerned are charged with safeguarding the pub-
lic health. Most important of all, in the medical
profession!
New Jersey has high standards which should be
maintained free from political influence. Bill 304
does not guarantee that, even though the Abell
report clearly states “the regulatory work of these
boards would in no manner be interfered with.”
Moreover, the purposes of the scheme as out-
lined in the Abell report do not seem fully real-
ized in the proposed legislation. In the report it
is stated:
“We recommend that a Bureau of Profes-
sional Registration be created in the Depart ~
ment of Education which will consolidate
these twelve examining and licensing boards
into one unit, with one Secretary instead of
the dozen now drawing pay. Great economies
in rents would likewise be effected.”
But the bill itself reads:
“The Commissioner of Education shall . . .
appoint a secretary of said bureau and such
clerical, technical and other assistants as may
be necessary, fix their compensation and pre-
scribe their duties . .
In short, while there will be one secretary, there
xoill be a lot of other jobs, under other names.
Insofar as Bill 304 covers the consolidation of
the financial functions of these professional boards
it has our hearty approval.
But we do believe the measure is weak in that
it is not emphatic enough in assuring the public
that their regulatory functions will not be mo-
lested; and that it is far too vague as to how
the promised economies in operation are to be
effected.
In brief the measure should be redrafted along
these 3 lines:
To consolidate the boards in matters of finance;
To preserve their standards of qualification,
notably in the professions which concern the pub-
lic health;
And lastly, to make definite, in the bill itself,
a guarantee that there will be real economy and
not sham economy!
THE WHITE HOUSE CONFERENCE ON CHILD
HEALTH AND PROTECTION
Reported by William G. Schauffler, M.D.,
Princeton, N. J.
The Conference on Child Health and Protection
called by President Hoover met in Washington,
D. C., on November 19, 1930, and continued through
November 22. The sessions were held in the group
of buildings centering around the Red Cross Build-
ing and the Hall of the Daughters of the American
Revolution. Conference headquarters was at the
Interior Department Building, and the general
meetings were held in Constitution Hall, which
holds about 5000 people, and which was filled at
the opening session on Wednesday evening, when
President Hoover made the opening address after
Secretary Ray Lyman Wilbur, M. D., Chairman
of the Conference, had welcomed the delegates.
Over 3000 delegates attended this meeting, com-
ing from more than 20 states. They represented
the tremendous interest shown in all parts of our
country for, child welfare, and were a remarkably
fine body of men and women. The work of the
conference was divided into 4 Sections as follows:
Section 1. Medical Service, subdivided into
(a) Growth and Development.
(b) Prenatal and Maternal Care.
(c) Medical Care for Children.
Section 2. Public Health Service and Adminis-
tration.
(a) Public Health Organization.
(b) Communicable Disease Control.
(c) Milk Production and Control.
Section 3. Education and Training.
(a) The Family and Parent Education.
(b) The Infant and Pre-School Child.
(c) The School Child.
(d) Vocational Guidance and Child Labor.
(e) Recreation and Physical Education.
(f y Special Classes.
(g) Growth Outside of Home and School.
Section 4. The Handicapped.
(a) State and Local Organizations for the
Handicapped.
(b) Physically and Mentally Handicapped.
(c) Socially Handicapped, Dependency and
Neglect.
(d) Socially Handicapped, Delinquency.
In preparation for this conference more than
150 committees and subcommittees had been gath-
ering material and collating it for consideration
during the past year, and the facts were stated
in a most intelligent and comprehensible manner.
Breakfast, luncheon and dinner groups were held
during the 3 days of the meetings, at which the
subjects could be talked over more informally than
in large group meetings.
On Saturday morning the 4 Section chairmen
presented consolidated reports, and the conference
was concluded with the “Consideration of Reports
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
59
by the Conference”, presented by the Chairman-
Secretary Hon. Ray Lyman Wilbur, M. D.
These conclusions, which will form the basis
of work in all parts of the country, were as fol-
lows: Every American child has the right to the
following services in its development and protec-
tion.
Every child should he understood.
(1) Every prospective mother should have suit-
able information, medical ■supervision during the
prenatal period, competent care at confinement.
Every mother should have postnatal medical super-
vision for herself and child.
(2) Every child should receive periodic health
•examinations before and during the school period,
including adolescense, by the family physician, or
the school or other public physician, and such ex-
amination by specialists and such hospital care as
its special needs may require.
(3) Every child should have regular dental ex-
amination and care.
(4) Every child should have instruction in the
school in health and in safety from accidents, and
every teacher should be trained in health programs.
(5) Every child should be protected from com-
municable diseases to which he might be exposed
at home, in school or at play, and protected from
impure milk and food.
(6) Every child should have proper sleeping
rooms, diet, hours of sleep and play, and parents
should receive expert information as to the needs
of children of various ages as to these questions.
(7) Every child should attend a school which
has proper seating, lighting, ventilation and sani-
tation. For younger children, kindergartens and
nursery schools should be provided to supplement
home care.
(8) The school should be so organized as to
discover and develop the special abilities of each
child, and should assist in vocational guidance; for
children, like men, succeed by the use of their
strongest qualities and special interest.
(9) Every child should have some form of re-
ligious, moral and character training.
(10) Every child has a right to a place to play,
with adequate facilities therefor.
(11) With the expanding domain of the com-
munity’s responsibilities for children, there should
be proper provision for and supervision of re-
creation and entertainment
(12) Every child should be protected against
labor that stunts growth, either physical or men-
tal, that limits education, that deprives children
of the right of comradeship, of joy and play.
(13) Every child who is blind, deaf, crippled or
otherwise' physically handicapped should be given
expert study and corrective treatment where there
is a possibility of relief, and appropriate develop-
ment or training. Children with subnormal or ab-
normal mental conditions should receive adequate
study, protection, training and care.
(14) Every waif and orphan in need must be
supported.
(15) Every child is entitled to the feeling that
he has a home. The extension of services in the
community should supplement and not supplant
parents.
(16) Children who habitually fail to meet nor-
mal standards of human behavior should be pro-
vided special care under guidance of the school,
the community health or welfare center, or other
agency for continued supervision, or, if necessary,
control.
(17) Where the child does not have these ser-
vices, due to inadequate income of the family, then
such services must be provided for him by the
community.
(18) The rural child should have as satisfac-
tory schooling, health protection and welfare
facilities as the city child.
(19) In order that these minimum protections
of the health and welfare of children may be every-
where available, there should be a district, county
or community organization for health, education
and welfare, with full-time officials coordinating
with a state-wide program which will be respon-
sive to a nation-wide service of general informa-
tion, statistics and scientific research. This should
include:
(a) Trained, full-time public health officials
with public health nurses, sanitary inspection and
laboratory workers.
(b) Available hospital beds.
(c) Full-time public welfare services for the
relief and aid of children in special need from
poverty or misfortune, for the protection of chil-
dren from abuse, neglect, exploitation or moral
hazard.
(d) The development of voluntary organizations
for children, for purposes of instruction, health and
recreation through private effort and benefaction.
When possible existing agencies should be co-
ordinated, to avoid overlapping. It is the purpose
of this Conference to establish the standards by
which the efficiency of such services may be tested
in the community, and to develop the creation of
such services. These standards are defined in
many particulars in the reports of the committees
of the conference. The Conference recommends
that the continuing committee, to be appointed by
the President from the conference, shall study
points upon which agreement has not been reached,
shall develop further standards, shall encourage
the establishment of services for children, and re-
port to the members of the Congress through the
President.
New Jersey was well represented at the Con-
ference by members of the State Medical Society
and laymen and women. Commissioner William J.
Ellis, of the Department of Institutions and Agen-
cies, was prominent in the work of Section 4.
State Health Department
STATE HEALTH LAWS
(A communication from D. C. Bowen, Director New
Jersey State Department of Health.)
Wide commendation is meeting the ‘‘Physicians’
Handbook”, prepared and distributed by the State
Department of Health. Simplicity and conciseness
of the new booklet of vest-pocket size for handy
reference are the characterizations of one of its en-
dorsers. Copies are available to physicians of the
state without cost and may be obtained by com-
municating with the department, at the State
House, Trenton.
Do you find it hard to keep in mind just what
matters you should report to boards of health and
when and how these reports should be made? It
is not surprising if you do. Regulations on the
subject are long and appear in several different laws
which are not easy to read nor to remember.
The Physicians’ Handbook lists under separate
headings subjects on which you are expected to re-
port, in accordance with various laws and regu-
lations, state-wide in effect. The booklet is ar-
ranged in a manner convenient for ready refer-
60
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
ence. Legal terms are avoided. It is concise, and
I believe it will be helpful to you. Will you not
look over the booklet now and note what it con-
tains. It will fit your pocket.
Acknowledgements have been most gratifying
to the department for the work involved. Dr.
James J. McGuire, of Trenton, Secretary of the
State Board of Medical Examiners, plans to give
each successful candidate qualifying in the board’s
examinations a copy of the booklet, which the State
Department of Health will supply.
The reportable communicable diseases, dog bites
of persons, epilepsy and mental deficiency, and
drug addicts under treatment are dealt with under
a uniform arrangement of sub-heads which in-
clude: (1) what diseases to report, (2) what facts
to report, (3) to whom to report, and (4) when
and how to report.
Reporting of diseases ' which occur on dairy
premises, and of venereal diseases, is discussed
under appropriate headings.
Physicians’ duties with respect to recording
births and deaths are explained in a concise way.
The busy physcian will find in the 12 pages of
this booklet information he frequently needs in
a form convenient for ready refei-ence.
In a foreword to the booklet, the department
said :
Physicians are usually the first who see cases
of communicable diseases in a community and are
able to give authoritative warning of their
presence.
Local health departments have been empowered
to enforce measures to prevent the spread of these
diseases, but no health department, however well
organized, can plan nor apply effective measures
to prevent their spread without a knowledge of
when and where cases occur.
Responsibility has also been placed upon health
departments to collect records of births and deaths,
and to preserve these records, so important to the
people of the state. Again it is the physician who
has knowledge of facts and conditions essential to
such records.
For the public welfare, therefore, state laws and
regulations have placed upon physicians the duty
of reporting cases of communicable diseases and
certain other ailments, and of filing or supplying
facts for certificates of births and deaths. A digest
of these state-wide, legal requirements, for the
reference of physicians, is given in this booklet.
Communications
IMPRESSIONS OF THE ANNUAL CONFER-
ENCE OF SECRETARIES OF CONSTITU-
ENT STATE MEDICAL ASSOCIA-
TIONS, 1930
Dr. George N. J. Sommer, M.D.,
Trenton, N. J.
This meeting was held at the American Medi-
cal Association Headquarters in Chicago, Novem-
ber 14-15, 1930. On the invitation of Drs. Mor-
rison and Reik, I attended this meeting and was
cordially received by the President, Dr. William
Gerry Morgan, Secretary Olin West, and various
members of the Board of Trustees, one of whom,
Dr. J. H. J. Upham, of Ohio, happened to be an
old class-mate.
The papers presented were quite notable and
quite to the point, dealing largely with present
day problems of the profession in its relations
with the general public.
The paper of Dr. R. L. Parker, of Des Moines,
on “Service for the Indigent Through Contract
with the County Medical Society’’, described a
plan which has been put into practice by 11 of
the county societies in Iowa and apparently is
working out satisfactorily. A close study of this
plan would solve this problem to the satisfaction
of physicians and public in rural counties at
least. (See editorial, this issue.)
Dr. F. C. Warnshuis, of Grand Rapids, Michi-
gan, read a paper on “The Relations of State
Boards of Medical Examiners to State Medical
Associations”; which seemed to be similar to
what we have in New Jersey, but which ar-
rangement for us seems to be in grave danger
from the Abell Report recommendations.
Dr. W. C. Rappelye spoke on the general sub-
ject of “Health Insurance’’ and gave some facts
relating to the systems in vogue in England,
Germany and other countries of Europe. No
solution for our country was advanced but the
data gathered by him will need to be considered
by us to solve our problem in this regard. “Co-
operation Between Medical, Public Health and
Educational Organizations” was discussed by Dr.
E. A. Myerding, of St. Paul, in a lengthy descrip-
tion of the method now in use in Minnesota. It
is an expensive, thorough program financed by
the State Medical Society and Social Service Or-
ganizations, under one head, and is working well;
an example of a good way to do a necessary work
under control, as it should be, of medical men.
Dr. F. C. Hammond, of Philadelphia, Editor of
the official organ of the Pennsylvania State Medi-
cal Society, presented his ideas on “What a State
Medical Society Journal Should Mean to the So-
ciety Membership”. This paper will bear inten-
sive study by medical men of any state. Our
Journal measures up to all of the standards he
established and is serving our membership ex-
ceptionally well.
The last, but not least, was a paper by Dr.
William H. Ross, President of the State Society
of New York, on “The Public Relations Com-
mittee”. This is the coming bulwark of the pro-
fession against the encroachments of State Medi-
cine and the problem was discussed in scholarly
manner by one who has given much of life and
time to study of professional relations with the
public. No doubt this paper will have a great
influence on this perplexing problem and its
solution.
After hearing all these papers on.' was struck
with the grasp of the various authors on the
great problems of the profession of our times,
and no doubt the papers will be of use to us in
New Jersey in solving our own problems.
I was personally much impressed with the re-
markable executive talents of Drs. Olin West,
Secretary, and Morris Fishbein, Editor, in
their sane attitudes toward the problems which
confront the medical profession.
MENTAL HYGIENE
(A letter from Dr. F. E. Williams, Medical Di-
rector, National Committee for Mental
Hygiene, New York City.)
The phenomenally rapid growth of interest in
all aspects of extramural psychiatry in recent
years has created several situations of consider-
able gravity, of which the shortage of adequate-
ly trained personnel is by far the most pressing.
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
61
The mounting interest of communities in child
guidance and other types of mental hygiene
clinics has already exhausted the never-suflicient
supply of specially trained psychiatrists for this
work, and unless physicians with the requisite
training and aptitude can be secured in greater
numbers, either the establishment of many new
clinic projects will be delayed, or, worse, their
functioning will be attempted by unprepared or
poorly prepared staffs.
To assist in lessening some of this shortage of
properly trained psychiatrists The National Com-
mittee for Mental Hygiene offers fellowships
toward acquisition of the special preparation
required. Details of these fellowships are con-
tained in the enclosed announcement, a repro-
duction of which in the columns of an early is-
sue of your periodical will be deeply appre-
ciated in the interests of modern medical edu-
cation.
Minimum Requirements for Applicants
These fellowships are designed to provide spe-
cial training for physicians who have had pre-
vious hospital training in psychiatry but who
wish to prepare themselves for extramural work
in the fields of child guidance, delinquency, edu-
cation, dependency, and industry.
Fellowships are open to physicians who are:
(1) Under 3 5 years of age.
(2) Graduates of Class A medical schools.
(3) Who have had at least 1 year of training
in a hospital for mental disease maintaining sat-
isfactory standards of clinical work and instruc-
tion. A longer period of hospital training is de-
sirable.
Applicants able to meet these requirements
will not be required to take competitive written
or oral examinations. Selections will be made
on the basis of length and type of previous train-
ing in formal psychiatry; on general fitness for
the work contemplated; and (in most cases) on
the results of a personal interview.
General Details of Fellowships
(1) These fellowships cover a period of train-
ing approximately 1 year in length.
(2) During this training period, trainees usu-
ally are assigned for 3 to 4 months’ periods at
such places as the Boston Psychopathic Hos-
pital; Judge Baker Foundation, Boston; Insti-
tute for Juvenile Research, Chicago and other
places of a similar nature, as well as to various
child guidance clinics located in Cleveland, Phila-
delphia and other cities. Assignments to these
training centers are not definite, however, and as-
signment to any given place will depend upon the
availability of instruction at such place, as well
as the special needs of the individual trainee.
Assignments are not made for more than 3
months in advance, and adheience for the year’s
training period to a fixed program in advance is
impossible.
(3) These fellowships carry stipends at the
rate of $2000 to $2500 for the 12 months’ period.
(4) Applications need not be filed within
stated periods but will be received at any time.
In the case of successful applicants, arrange-
ments will be made to begin work whenever
mutually convenient to the applicant and to the
director of the training center to which the ap-
plicant is first assigned.
Applications or inquiries for further informa-
tion should be sent to Dr. Frankwood E. Will-
iams, Medical Director, National Committee for
Mental Hygiene, 37 0 Seventh Avenue, New York,
N. Y.
PRE-SCHOOL AND SCHOOL PIIYSICAD
EXAMINATIONS
Harold Edwin Wright, M.D.,
Princeton, N. J.
(A letter to the Journal, under date of Novem-
ber 11, 1930)
In the issue of the Journal for October 1930,
under School Health Department, was an article
entitled, “Preliminaries to the School Doctors
Examination’’.
It appears much like a harmless little article
and hardly worth commenting upon but its prac-
tical worth, while of little value should be dis-
cussed. Some writers on questions relating to
school matters always seem to think the teacher
has plenty of spare time on her hands, and
thoughtlessly suggest some new idea to consume
some part of her day in helping to carry out
some suggestion; very often a foolish one.
After about 20 years experience as a school
medical inspector, connected with a school sys-
tem of very high standing, I feel I am compe-
tent to express myself with some judgment of
experience. Where can there be any improve-
ment in the mental attitude of a. child who re-
ceives a physical examination the first week of
school or the third week? What can a teacher
do to prepare a child to meet a school medical
inspector, if the inspector does not understand
how to meet and handle children? Also1, how
does a child’s mental status improve a physical
defect? If the examination consists of a psych-
ologic laboratory test, then the mental prepara-
tion could be appreciated, but the examination
of eyes, throat, ears, posture, heart, lungs, etc.,
needs no mental preparation; such organs have
either a defect or no defect, which is readily as-
certained. A child to be examined physically in
school is in a very different class from a child
who approaches a physician for some ailment.
Delaying the examination for a few weeks is a
small matter, very true, but what have you ac-
complished by such a delay?
Observation in the class room by the teacher,
to ascertain any peculiar traits of a child, such
as likes, dislikes, habits, etc., will be of value pos-
sibly to the teacher but not to the doctor. The
efficient school inspector does not need assist-
ance of the teacher to discover whether a child
is undernourished. In comprehensive school sys-
tems the children are weighed each month by the
nurse and records are kept, which enables the
school physician to bring influence to bear at
home. While the duties of the nurse are multi-
plying and her responsibilities are greater, yet
she should always be at the disposal of the medi-
cal inspector to assist him both in conducting
physical examinations and follow-up work on
detected defects.
Just how much progress and thoroughness is
made in other places, the writer does not know.
However, we do feel that in Princeton every side
of the question of school medical inspection is
practiced. For many years we have been very
particular concerning health of the teachers and
a physical examination of each one is made an-
nually. We are laying particular stress upon the
pre-school examinations of children. These ex-
62
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
animations are only conducted in the presence of
the parent. They are by far the most important
examinations made. They enable the child to
enter school with all defects corrected, and the
parent of the child is taug-ht to appreciate the
value of such corrections and how to care for a
child that is not normally developed. In Prince-
ton these examinations are conducted every
spring and are becoming each year more popu-
lar. Place the child in school with 100% physical
condition and the teacher will have much less
trouble with the mental development. To do
this, we do not need any foolish training of a
child’s mind to meet the doctor. Also, such ex-
aminations of pre-school ages conducted in the
presence of the parent can be done with the
clothing removed. We sincerely hope the remov-
al of all clothing of each school child, as has
been suggested, will never be practiced. It
would create, and justly, a storm of criticism,
and in the opinion of the writer would require
possibly 2 examiners, a man and a woman. This
is unnecessary expense to the taxpayer for ques-
tionable results. It is a procedure which is not
required if pre-school age examinations are em-
phasized. It is very hard for the writer to un-
derstand why so great a weight is placed upon
a foundation the strength of which has not been
estimated. If we have knowledge of the child’s
physical condition when it commences its school
career, we know what to expect and what can be
done.
This view , certainly is a practical one;
it is an inexpensive one; and it eliminates a
great deal of the so-called gallery play or ideal-
istic impracticabilities. The rural districts can
afford thorough pre-school physical methods
when they can see the results, but cannot afford
the many useless methods advocated for the
school child after it has entered upon its career.
It seems strange that more common sense and
not so much theory does not prevail.
Another point that must be borne in mind is
the difference in methods used in the larger com-
munities and those used in the rural districts.
It is very possible for the larger towns, where
enrollment is very large, to practice what is be-
ing done in New York; i.e. for the teachers in
each grade to set aside 1 day for gross inspection
of the pupils for enlarged tonsils, eye-readings,
hearing tests, and detecting any unusual abnor-
mality; I do not mention teeth because they
should come under the dental department. This
procedure may have its valuable side in places
where thousands of pupils are to be examined,
but it would not fulfill the law in New Jersey
where it is specified that examinations must be
made of each pupil, each year, by a medical in-
spector. Should there be a change in the pres-
ent system, the writer sincerely hopes it will be
the development of a system in regard to the
pre-school medical attention. Also, if a child
enters school pronounced free from defects, an-
nual physical examinations would be super-
fluous. Examinations upon entrance to school
and subsequent ones about the third and sixth
years would cover the requirements.
While the duties of the school nurse are in-
creasing each year, so are the duties of the
medical inspector. Communicable diseases re-
quire his daily attention, and should never be
diagnosed by any one except a physician. Con-
trol of them requires close cooperation of the
Health Officer of the community. Preventive
methods now so widely used for immunization
against these diseases requires much more time
of the medical inspector. In addition to all this
the medical inspector is at the disposal of the
athletic de_partment for any injuries or opinion
in matters pertaining to the medical side of that
department. There is plenty for the nurse and
doctor to do and do thoroughly without the ad-
dition of questionable ideas.
ABELL COMMISSION REPORT
(A letter, advising caution with regard to legis-
lative matters, from Dr. Elias J. Marsh, Treas-
urer of the Medical Society of New Jersey.)
I have received from the State Board of Medi-
cal Examiners a copy of the proposed law to con-
solidate the administrative work of various pro-
fessional examining boards, together with notes
on the experiences of other states where similar
plans have been tried. From these it appears
that the results have not been altogether satis-
factory, and our Board seems to fear that the
proposed plan would hinder them in some of the
work they are now doing.
S. 304 is one of a series of acts offered by the
so-called Abell Commission for the general re-
organization nad simplification of the state govern-
ment. The great need 'of such a reorganization is
generally recognized, and I think there is little
question among our people that in its main lines
the plan outlined by the Commission is wisely and
soundly conceived. Perfection in all details is
hardly to be expected in a work of this character,
and opinions will differ; there are always minor
defects which are subject to just criticism. Unfor-
tunately, opposition, even when just in itself, on
account of what are really minor points, im-
portant though they may seem to those inter-
ested, often strengthens the resistance to great
and necessary reforms offered by interested per-
sons for selfish reasons. It would be a great mis-
fortune for the state, and a heavy charge against
those responsible, if this great opportunity to re-
form our government should be lost by the aid
of objections raised against details, however valid
the objections in themselves.
I am not sufficiently familiar with the opera-
tions of the Board of Medical Examiners to pass
an opinion, but most of the mentioned difficulties
appear to me incidental, and remediable by
amendment, rather than inherent. But even
granting them as serious as the members of the
Board seem to regard them, we should remember
that we are citizens before we are physicians, and
the state is entitled to priority of consideration
even before our profession — supposing there is
any conflict, which I did not admit. After all, the
work of the Board of Medical Examiners, like
all other boards, is for the welfare of the people,
not of the profession, and if the best advantage
of the state demands some sacrifice on our part —
mind, I say if — it ill becomes that profession
which is justly proud of its self-sacrifice and pub-
lic spirit to refuse it now. By all means let us
strive for such changes in the bill as will con-
serve the advantages for the public service en-
joyed by the present board, without lessening the
main puropse of the reform, but I sincerely trust
that our Welfare Committee and the leaders of
our society, as well as the members of the Board
themselves, will not place the society and the pro-
fession in the position of hindering in any way the
most hopeful promise of civic reform seen in New
Jersey in a generation.
(Signed) — Elias J. Marsh.
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
63
AMERICAN PHYSIOTHERAPY ASSOCIATION
(A letter transmitted to us by Dr. Harold D.
Corbusier, with approval for publication.)
The New Jersey Chapter of the American Phy-
siotherapy Association, a national association of
physical therapy technicians organized shortly
after the war, has established a registry and ap-
pointment bureau for its members in this state.
Requirements for membership in this associa-
tion are as follows and are approved by the
Council on Physical Therapy of the American
Medical Association.
Active members are those having had 1 year
of practice in physical therapy within 2 years of
graduation from:
(1) An approved School of Physical Therapy.
(2) An approved School of Physical Education
and satisfactory completion of an approved
course of physical therapy.
(3) An approved School of Nursing and satis-
factory completion of an approved course of
physical therapy.
Junior members shall be persons fulfilling the
requirements of active members, except 1 year of
practice shall not be necessary; nor shall they
have the power to vote.
The standards of ethics of the American Phy-
siotherapy Association shall be as far as possible
those of the American Medical Association. All
members shall practice only under the prescription
and direction of a licensed physician. . Therefore,
only persons having the best possible training
may register in this bureau. It is the place to
which the physicians may apply when in need of
well trained physical therapy technicians either
in their private offices or in hospitals.
The registry is under the direction of Miss
Jean Smith, Beth Israel Hospital, Lyons Avenue,
Newark, N. J. Telephone — Terrace 3-5700.
VIOLATIONS OF MEDICAL PRACTICE ACT
(A letter from Dr. J. J. McGuire, Secretary of the
State Board of Medical Examiners.)
Schuyler C. Pew, of Perth Amboy, was found
guilty of practicing medicine without a license, on
September 8, by the Judge of the New Bruns-
wick District Court. Mr. Pew held himself out as
a masseur and also gave electric treatments.
Theodore DeDragic, of Atlantic City, who held
himself out as a Vienna physician and physio-
therapist, was found guilty of practicing medicine
without a license on September 10, and on failure
to pay the penalty was committed to jail for 30
days.
Emma L. Garwood, of Beverly, who advertised
as a masseuse and electrotherapist, pleaded guilty
in the Court of Common Pleas of Burlington Coun-
ty, on September 11, to a charge of practicing
medicine without a license.
Frank Weber, of Burlington, pleaded guilty in
the Court of Common Pleas, of Burlington Coun-
ty, on September 11, to a charge of practicing
medicine without a license.
Mary A. Wilson, a psycho-analysist, of Newark,
on September 18, paid the penalty for practicing
medicine without a license.
Thomas Parusis, of Jersey City was found guilty
in the First District Court of Jersey City, of prac-
ticing medicine without a license. On failure to
pay the penalty, he was committed to jail for 30
days.
Daniel S. Priest, druggist, of Toms River, in
September 1930 paid the penalty for practicing
medicine without a license.
Ernest M. Bick, of South Orange, who pre-
scribed medicine to be taken internally, was tried
in the Second District Court, Newark, on Octo-
ber 3, on a charge of practicing medicine without
a license, and was convicted. He had previously
been convicted on January 28.
Lillian Kallila, of Jersey City, on October 7,
pleaded guilty in the First District Court of Jer-
sey City to a charge of practicing medicine with-
out a license and paid the penalty.
Aino S. Mateinheimo, of Jersey City, on October
7, pleaded guilty in the First District Court of
Jersey City to a charge of practicing medicine
without a license and paid the penalty.
Eugene Gebauer, of Newark, who was prac-
ticing electrotherapy and hydrotherapy, was found
guilty of practicing medicine without a license,
by the Judge of the First District Court of New-
ark, on October 8. He refused to pay the penalty
and was committed to jail for 5 days.
Nicklos N. Barron, of Newark, who prescribed
medicine to be used both externally and internally,
was found guilty on October 20, by the Judge of
the Second District Court of Newark, of practicing
medicine without a license and paid the penalty.
Abram Taub, druggist, of Pompton Plains, was
found guilty of practicing medicine without a li-
cense on October 21, by the Judge of the Paterson
District Court.
William Miles, of Atlantic City, on October 24,
paid the penalty for practicing medicine without a
license.
Solomon Boxer, druggist, of Ventnor, was found
guilty on October 29, by the Judge of the Atlantic
City District Court, of practicing medicine with-
out a license. The defendant had a dffiloma in his
drug store showing that he was a graduate of a
college of naturopathy, but prescribed drugs for
his patients.
Frieda Korte, of Atlantic City, who was giving elec-
tric treatments and colonic irrigations, was found
guilty by the Judge of the Atlantic City District
Court, on a charge of practicing medicine without
a license. This was the third time that Mrs. Korte
had been convicted and as she was unable to pay
the penalty, she was committed for 60 days.
George Lezenby, Jr., of Atlantic City, a naturo-
path, was found guilty on October 29, of practic-
ing medicine without a license, by the Judge of
the Atlantic City District Court. He failed to ap-
pear in Court and the Judge ordered him com-
mitted to jail for 60 days, but when the commit-
ment was served he paid the penalty.
Charles Schaefer, Sr., of Oaklyn, in October, paid
the penalty for practicing medicine without a li-
cense.
Charles Schaefer, Jr., of Oaklyn, in October, paid
the penalty for practicing medicine without a li-
cense.
Charles S. Newell, of Merchantville, a naturo-
path, paid the penalty on November 5, for prac-
ticing medicine without a license.
Ehrgott W. Gebhardt, of Merchantville, a drug-
gist, paid the penalty on November 5, for practic-
ing medicine without a license.
COUNCILLOR DISTRICT MEETING
(A letter from L. Cook Osmun, M.D.)
The first Councillor District Meeting of the
First Councillor District will be held on Thurs-
day evening, February 12, 1931, in the Academy
of Medicine, Newark. The main address will be
€4
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
by Dr. W. H. Ross, of Brentwood, L. I., and we
are planning to make this a large affair.
THE WAI/I WHITMAN
To the Editor: The American Medical Associa-
tion will hold its annual meeting in Philadelphia
June 8-12, 1931, and I am writing that you may
announce throughout the state the convenience
and desirability of stopping at THE WALT
WHITMAN during the period of that meeting.
As you know, we are but 10 minutes from the
center of Philadelphia — busses stopping at our
doors at all times.
‘A New Jersey hotel for New Jerseymen”.
Sincereley yours,
Chas. F, Krapp, Manager.
Current Events
MINUTES OF THE WELFARE COMMITTEE
Trenton, New Jersey,
November 9, 1930.
Pursuant to call, regularly issued under author-
ization of the President of the Medical Society of
New Jersey. Dr. George N. J. Sommer, the first
meeting of the newly appointed Welfare Commit-
tee of the State Medical Society was held at the
Stacy-Trent Hotel, Sunday, November 9, 1930.
The meeting was called to order by President
Sommer, who anounced that the objects of the
meeting would be, first, to organize by election of
a chairman, and then to transact any business
pertaining to the winter’s program.
Roll call disclosed the following members pres-
ent: Coleman, A. H.; Conaway, Costill, Dandois,
Davis, Ely, Green, Haussling, Hunter, Lippincott,
McBride, McMahon, Morrison, Morrow, Nafey,
North, Schauffler, Schlichter, Sewall, Sherman,
Sommer, Tracy. Excuses were received from Drs.
Clayton, Donohoe, D. Leo Haggerty, Londrigan
and Ward. Vice-Presidents John F. Hagerty, and
Quigley were present by invitation, and Drs. Kel-
ley and McGuire were present from the State
Board of Medical Examiners.
The President called for nominations for the
chairmanship and Dr. A. H. Lippincott was nom-
inated and elected by unanimous vote. The Presi-
dent thereupon called Dr. Lippincott to the chair.
The Executive Secretary presented the following
report:
Report of the Executive Secretary to the Wel-
fare Committee
The Executive Secretary has at the moment only
a short report to submit. The work of his office
has proceeded in routine manner during the sum-
mer, and at present everything is progressing
smoothly and satisfactorily. The public educa-
tional program will be continued this winter as
heretofore, and we have reason to believe that ra-
dio broadcasting will be conducted under the aus-
pices of 5 county medical societies in whose ter-
ritory proper facilities exist; to wit: Atlantic, Ber-
gen, Essex, Hudson and Monmouth. The Field
Secretary, Mrs. Taneyhill, is carrying a program
this year that is even heavier than through pre-
vious seasons. With the kindly assistance of the
State Board of Education, she has arranged to ad-
dress nearly all the school organizations of the
state, stressing particularly the importance of
mental hygiene, but presenting also on occasion
the other lectures of her series.
It is early to predict anything about the ap-
proaching General Assembly of New Jersey, but
the election returns and certain information that
has leaked out from political headquarters per-
mit us to draw some inferences. In all proba-
bility, the next State Senate will be in the hands
of our friends; that is to say, that Senator Wol-
ber, who has always been cooperative, is said to
be slated for the post of President of the Senate;
Senator McAllister, of Cumberland, is to be the Re-
publican Senate Floor Leader; and our very good
and reliable friend, Dr. Blase Cole, is to be the
Democratic Senate Floor Leader. If those selec-
tions are confirmed we may feel reasonably safe as
regards the Senate attitude toward public health
legislation. In the House of Assembly, the situa-
tion is less favorable. The Republican slate is
said to be — Wise, of Passaic County, for Speaker,
and Otto, of Union County, for Floor Leader; the
first named is a cultist of variegated hue and we
need expect no favors at his hands.
At the Annual Meeting of the State Society, a
resolution was adopted upon motion of Dr. Mor-
rison, seconded by Dr. Quigley, that the Welfare
Committee be requested to consider the necessity
ior or advisability of securing legislation to con-
trol or prevent the employment of unlicensed
physicians by municipal, county and state institu-
tions. That request is hereby respectfully directed
to your attention.
We have not as yet, of course, any specific
knowledge of bills to be introduced into the Gen-
eral Assembly but experience leads us to expect
the usual crop of objectionable medical bills. The
Surgery Control Bill that was under consideration
at the Legislatures of 1929 and 1930 is more than
likely to make a reappearance. The Welfare Com-
mittee of last year left further consideration of
that question in the hands of a special committee
composed of Drs. John Hagerty, W. G. Schauffler,
and Joseph G. Coleman. The special committee
on the Hospital Lien Law, under the chairman-
ship of Dr. Londrigan, accomplished the greater
part of its task last year but was held over to con-
sider whether further action in the future is de-
sirable.
There is no other unfinished business.
Respectfuly submitted,
Henry O. Reik, M.D.,
Secretary, Welfare Committee.
At the suggestion of the Chairman, the report
was accepted and ordered to be placed on file.
At the request of the President, Dr. Sommer,
the Executive Secretary presented a communica-
tion from the Mercantile Finance Corporation of
New Jersey, with offices at 32 E. Hanover Street,
Trenton, which, in effect, set forth a plan for the
collection of physicians’ bad accounts, and for the
loan of money to patients for the payment of medi-
cal bills or for the payment of prospective sur-
gical procedures.
Dr. Reik called attention to the fact that a sim-
ilar proposition, offered by the Gilbert Acceptance
Corporation, of Newark, had been rejected last year
by the Welfare Committee after a very thorough
investigation by the Secretary and, later, by a
special committee.
Dr. Sommer stated that he knew nothing about
the proposition and presented it only because it
had come to him officially.
Dr. North remarked that he had seen a copy of
the offer, had read it carefully, and did not con-
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
sider it worthy of endorsement by the medical pro-
fession.
Upon motion of Dr. McBride, the committee
voted unanimously to decline further considera-
tion of the proposition.
At the request of Dr. Morrison, the Executive
Secretary read a letter z’eceived from Dr. Law-
rence Greeley Brown, of Elizabeth, N. J., complain-
ing about the manner in which the Medical Bill
Adjustment Committee of Essex County had acted
in reference to settlement of a professional ac-
count rendered to the Aetna Insurance Company
for services to an injured man.
After some discussion, it was decided that this
matter should be referred to the Essex County
Medical Society because the complaint dealt with
the acts of a, committee in that district.
Quoting from the Transactions of the Medical
Society of New Jersey in annual session at Atlantic
City June 1930, the Executive Secretary called at-
tention to action taken by the House of Delegates,
upon motion of Dr Morrison, seconded by Dr.
Quigley (Transactions, page 42), .calling upon the
Welfare Committee to consider what action should
be taken with reference to the employment of un-
licensed physicians by municipal, county and state
institutions.
After discussion, participated in by Drs. Kelley,
Coleman, Costill, McGuire, Nafey and Morrow, Dr.
Morrison moved that this matter be referred to a
special subcommittee, to act in cooperation with
Drs. McGuire and Kelley, of the State Board of
Medical Examiners, for investigation of this ques-
tion and later report to the Welfare Committee.
The motion was adopted and the Chairman ap-
pointed the committee as follows: J. Bennett Mor-
rison, Chairman; R. H. M. Davis and Herbert W.
Nafey.
Dr. McBride called attention to the fact that
during his presidency of the State Society he had
forwarded to the Governor of the state of New
Jersey the names of 3 physicians from whom the
Governor might select an appointee for the State
Board of Medical Examiners to fill the vacancy
which would occur at the expiration of Dr. Char-
les B. Kelley’s term, and stated that up to the
present time the Governor has failed to act. He
felt that the Medical Society is not being accorded
proper respect and that the Governor is failing
to perform his duty.
Upon motion of Dr. Schauffler, it was decided
to request the Chairman of the Board of Trustees
to call Governor Larson’s attention to this ques-
tion again, and to support Dr. McBride in his ef-
forts to secure official action.
Both the Executive Secretary, and the Secretary
of the Board of Medical Examiners, called the
Welfare Committee’s attention to newspaper re-
ports of the Abell Legislative Committee’s pro-
posal to transfer the work of the Medical Exam-
ining Board, and other similar bodies, to the State
Board of Education.
After discussion by Drs. McGuire, Schauffler,
North, Morrison and Schlichter, a motion was of-
fered by Dr. Schlichter that a committee of 5 be
appointed to consider the Abell Committee’s report
and to later advise the Welfare Committee what
action might be advisable.
Dr. McGuire offered as an amendment that the
proposed committee be instructed to confer with
the Board of Medical Examiners and other sim-
ilar groups concerned in the proposed change.
Dr. Schlichter accepted the amendment and the
amended motion was duly adopted.
The Chairman appointed the following commit-
tee: Andrew F. McBride, Chairman; Charles H.
65
Schlichter, Henry B. Costill, W. G. Schauffler, and
T. B. Lee.
Dr. Kelley reported upon the present status of
osteopathy and chiropractic in New Jersey, say-
ing that he did not believe either of these groups
would attempt to secure special legislation this
year but that he anticipated an effort on the part
of the naturopaths to procure special' privileges.
Dr. John Hager ty, as Chairman of the subcom-
mittee on the Surgery Bill, stated that his com-
mittee would report at a later meeting.
The Executive Secretary presented a document
prepared by Dr. Morrison in explanation of the
State Society work and the manner in which the
Society’s funds are expended, and recommended
that this be printed in the form of booklet pre-
viously used with reference to auxiliary matters
and in explanation of cultism, and that these book-
lets be distributed for the edification of members
of the State Society and for the use of officers of
county societies in collecting dues and in pro-
curing new members.
A motion was duly passed authorizing publica-
tion and distribution as recommended.
The meeting then adjourned.
Henry O. Reik, M.D ,
Secretary, Welfare Committee.
SPECIAL MEETING
A special meeting of the Welfare Committee
was held at the 'Stacy -Trent Hotel, Sunday, De-
cember 14, at 3 p. m., with the Chairman. Dr. A.
Haines Lippincott, presiding.
The following members answered to roll call:
Bloom, Clayton, A. H. Coleman, J. G. Coleman,
Conaway, Dandois, Davis, Donohoe, Ely, Green, D.
Leo Haggerty, Hunter, Larkey, Lippincott, Londri-
gan, McBride, McMahon, Morrill, Morrison, Mul-
ford, Nafey, North, Schauffler, Schlichter, Sewall,
Sherman, Sommer and Tracy. The following sent
excuses: Brown, Haussling and Lee. The following
invited guests were present: John F. Hagerty,
Paul M. Mecray and James J. McGuire.
The Chairman called for the report of the Ex-
ecutive Secretary, and Dr. Reik asked permission
to present his report in sections in order that the
first section might be acted upon as promptly as
possible because some members interested in that
portion of his report would want to be excused at
3.30 p. m. to attend another meeting.
Report of the Executive Secretary
(Section 1)
There are several matters of interest to be pre-
sented to the committee today, but inasmuch as
there is to be another meeting at 3.30 p. m„ which
must be attended by some of our members, a con-
ference of representatives of organizations affected
by proposed legislation growing out of the Abell
Commission’s report, it seems best to list that
subject first.
Since the last meeting of the Welfare Committee,
on November 9, the Abell report has been made
public and several legisative acts designed to con-
vert that commission’s recommendations into law
have been introduced into the General Assembly.
On Saturday, November 29, Dr. McBride and the
Executive Secretary traveled to Morristown for
an interview with Senator Abell, the results of
which were quite satisfactory. On December 1,
Senate Bill 304 was introduced, and the 3 bills
which affect the State Board of Medical Examin-
ers have since been made available for study. S.
260 provides for establishment of a centralized
66
JOURNAL OK THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
control and uniform system of accounting for the
money received and expended by the state. S. 262
provides for an improved budgeting plan to take
the place of the existing unsatisfactory method.
S. 304 is a special act designed to bring all of
the Boards of professional examination and licen-
sure under a central bureau in the State Depart-
ment of Education. It is the last named bill which
has caused most public discussion, though objec-
tion has also been made to S. 262. On Sunday, De-
cember 7, representatives from several of the pro-
fessions and Boards met in Trenton to confer with
our own subcommittee under the chairmanship of
Dr. McBride; the other groups present including
particularly the dentists, pharmacists, and under-
takers and embalmers. On Thursday, December 11,
at a public hearing on S. 262, we were represented
by President Sommer. Announcement has been
made that a public hearing will be given Tuesday,
December 16, on S. 304.
At this point I wish to ask your consideration
of 2 or 3 possible danger spots in the manner of
dealing with this proposed legislation. First, per-
mit me to warn against a too intimate alliance with
the organizations that are opposing this legisla-
tion. That phrase may sound queer, coming from
me, in view of my previous efforts in the direc-
tion of cooperation. It was I, for instance, who
3 years ago brought about the cooperative re-
lationship with the pharmacists. But, please keep
this in mind — that while I have always advocated
cooperation, I have never recommended amalga-
mation. We may, indeed we should, confer with
the other organizations, but we should be ex-
tremely careful to avoid responsibility for actions
they may take, and extremely cautious about
entering into any conference that may in-
volve us in an obligation to support a ma-
jority decision. That is a very important point to
keep in mind. Already, newspaper articles have
appeared from one of those groups that our so-
ciety certainly could not endorse.
I am informed that at the public hearing last
Thursday some of those groups were represented
by special agents, attorneys, and ex-members of
the legislature. I trust this society will not be
led into joining in such a procedure or into fol-
lowing that example. It would be derogatory to
the dignity of our profession and it would be in-
jurious to the standing we have acquired through
6 years of following a different policy. Incidentally,
such methods rarely, if ever, accomplish the in-
tended purpose, and they do constitute a waste
of money. Members of this group present today
can better represent you and accomplish more
satisfactory results than can any attorney or paid
lobbyist in the United States.
Further, permit me to express the opinion that
we are in grave danger of being swept into a
false position through the influence of mob psy-
chology. The appearance of these legislative bills,
indeed the preceding newspaper stories about what
the Abell report would contain, planted in our
minds a fear that something terrible was going
to happen. That fear has grown to the point
where we are in danger of acting unreasonably.
I have heard much talk about these bills but most
of it has been irrelevant, based upon fear rather
than study of the bills, and some of it has en-
tirely misrepresented the apparent intent and the
actual wording of the bill. I have heard it argued
that these bills propose abolition of the Boards of
Examiners, substitution of examinations by per-
sons incapable of conducting appropriate ex-
aminations, the employment of an immense force
of adjunct employees to carry on the work, and
the application of funds properly received by the
Boards to State work other than that heretofore
carried on by the Boards. There is not a word in
either of the laws to justify any of those criticisms.
I am not a prophet and I cannot predict with cer-
tainty what will happen if those laws are enacted,
but that is not the question before us at the
moment; the question calling for our first con-
sideration is — what do these bills propose?
I do not see how the medical profession can
consistently oppose bills 260 and 262, for they
offer to the state exactly what all good citizens
have been demanding whenever the wastefulness
or the dishonesty of state government has been
under discussion. S. 262, to which exception has
been noted, proposes for the state exactly what
this society has had for years and what it held so
precious as to rewrite into its new Constitution
and By-Laws. The budget system and central
control of all monies is one of the cardinal prin-
ciples of the business conduct of this society.
What does S. 304 say? Stripped of all excess
verbiage, which for some inexplicable reason is
made a part of all legislative acts, it provides:
(1) For creation of a bureau within the De-
partment of Education “for the centralization of
records’’ and “for the administration of the
financial operations of the several examining and
licensing Boards”, at the same time “preserving
the entity and identity” of such Boards, and that
all monies received by such Boards “shall be paid
into the State Treasury” and that all expenditures
of said Boards shall be in accord with the state
budgeting system.
(2) Authority is conferred upon the new bureau,
specificially, “to manage and regulate the financial
operations of the several Boards”; to “receive and
pay over to the State Treasury all monies col-
lected by the Boards”; and to issue licenses and
certificates of registration when and as approved
by the said Boards”.
(3) “Requests for appropriations shall be sub-
mitted by said Boards to the bureau”, and the
bureau shall pass approved requests to the Budget
Committee, which in turn submits a report to the
Legislature as a basis for the appropriation of
funds, “to the end that expenses for maintenance,
operation and administration of said Boards shall
be appropriated from the funds collected by the
Boards or from the free treasury funds of the
state”.
(4) “Nothing contained in this act shall be
construed to conflict with the examining, regu-
lating and general supervisory functions of the
State Boards.”
I am unable to detect anything very alarming
in those provisions. I would suggest 3 slight
change?, in the form of amendments: 1 believe
that administration of the bureau might better
rest with the Board of Regents than with the
Commissioner of Education; that is, something
comparable to the New Y'ork plan. Secondly, a
verbal change in the provision for appropriations
might be made so as to assure annual appropria-
tion of a sum not less than that of the receipts of
the Board. At a meeting of the Tristate Medical
Conference one week ago, I reported our concern
over this pending legislation, and the President
of the Pennsylvania Society, Dr. Ross V. Patter-
son, Dean of Jefferson Medical College, and who
is better informed than most of us concerning
medical education and Medical Licensing Boards,
stated that Pennsylvania now has practically the
same legal provisions and that he would advise
us to accept the proposed laws because he believes
they will work out to our advantage. The ex-
periences of New York and Pennsylvania consti-
tute the answer to some of the protests that this
J-n„ 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
G 7
proposed legislation is unique and impracticable.
Thirdly, I would insist that the State Bar Exam-
ining Board and the Realtors’ Board be included
in the law.
The most pronounced criticisms of the Abell
Commission plan seem not to be based upon the
proposed laws themselves but upon suspicion and
fear of how' such laws may be enforced. That is
a criticism of the American political system rather
than of these special acts, and I think we should
study these acts carefully before assuming a pub-
lic stand in opposition.
The Chairman: The first section of Dr. Reik’s
report is before you for action.
Dr. McBride: I am opposed to the transfer of
these licensing Boards to the Department of Edu-
cation for the reason that I am afraid such trans-
fer wTill enable, or will result in, bringing these
matters under control of politicians. As to sub-
stituting the Board of Regents for the Commis-
sioner of Education, I would like first to know
something more than I do now about the Board
of Regents.
As to S. 262, I think we should insist upon a re-
turn to our Board of all the monies turned into
the Treasury by the Board. That amendment, sug-
gested by Dr. Reik, is a good one.
Dr. Schauffler: I wonder if Dr. Sommer would
like to tell us something about the hearing on 262
last Thursday.
Dr. Sommer: A hearing was held on that bill
last Thursday and I attended along with repre-
sentatives of the dental and pharmaceutical asso-
ciations, as arranged at the conference last Sun-
day. It seems that there is to be another hear-
ing on that bill, for I have received a message
stating that S. 262 and S. 304 will be considered
further at the hearing announced for Tuesday,
December 16.
The main opposition to 262, as developed last
Thursday, was on the score of “dedicated funds”
Everybody wanted to know what dedicated funds
meant. The school teachers, for instance, feared
that might interfere vrith their pension fund, and
I noticed that their attorney, Mr. McCarter,
wanted an assurance written into the bill to make
it clear that such fund would not be interfered
with.
Dr. Liva spoke for the Medical Examining Board
and the medical profession and Dr. Forsythe, of
this city, spoke for the dentists. The conference
committee, of which I am a part, came to the con-
clusion that it would be wise to have an attorney’s
opinion on some parts of these bills and has
asked - Mr. McCarter to interpret those bills in
so far as they relate to the medical profession.
Senator Richards, who did most of the , cross
questioning, tried to keep away from any promise
guaranteeing a return to the Boards of their own
funds.
Dr. McBride: We had a meeting of the Passaic
County Medical Society last week and passed reso-
lutions opposing S. 262 and I will ask Dr. Reik
to read those resolutions.
Dr. Reik: Several of the county societies have
passed such resolutions and I have been informed
of such action by the Atlantic, Monmouth and
Passaic County Societies and by the Physicians’
Association of Woodbury. The Passaic County
resolutions, asked for by Dr. McBride, are as fol-
lows :
“We the members of the Passaic County Medi-
cal Society, respectfully request that you oppose
Senate Bill number 262 in its present form.
We contend that unless the bill is amended to
make mandatory an annual appropriation equal
to the amount of money collected by the State
Board of Medical Examiners during the year the
cause of public health will be endangered.
This money is necessary for the proper execu-
tion of the work engaged in by the State Board
of Medical Examiners in the interest of public
health. We feel that this money should be avail-
able to the Board without any uncertainty of ap-
propriation.
We know that it has always been the desire
and wish of the State Board of Medical Examin-
ers to have its accounts audited by the proper au-
thorities and we heartily endorse this principle.”
Dr. Morrison: I move that we endorse and adopt
the resolutions sent by the Passaic County Medi-
cal Society.
This motion was seconded and unanimously
adopted.
Dr. Morrill: I understand that action applies
only to S. 262.
Dr. Morrison: Yes. Now as to S. 304, I feel that
we have perhaps not sufficiently studied that bill
to justify flat opposition. I have read the act
carefully and it seems to me to guarantee keeping
the examining and licensing in the hands of the
respective Boards; it doesn’t propose to do any-
thing to such Boards except to govern their money
affairs. I am inclined to think it would be a good
thing to approve this legislation if we can secure
the amendments that have been suggested.
Dr. Hunter: I would like to ask how the Board
of Regents is constructed, whether by appointment
or by election, and whether anybody here knows
the members of that Board?
Dr. Schauffler: I know the President of that
Board very well indeed, and am sure that Mr.
Jeffers is a thoroughly trustworthy individual.
Dr. Morrison: I would like to say that our limit-
ed experience with the Board fully justifies that
recommendation. When the Chairman of our
Post-Graduate Instruction Committee and the Ex-
ecutive Secretary had occasion to confer with
the Board of Regents regarding plans of the State
Medical Society and Rutgers University, Mr. Jef-
fers treated them with the utmost courtesy, showed
great interest in our educational work, and prom-
ised his hearty support. I have thought for sev-
eral years that this society should endeavor to
secure an association with the Board of Regents
similar to that existing in New York.
Dr. Morrill: I think that Dr. Reik and Dr. Mor-
rison have hit the nail pretty squarely on the head
in regard to these bills, namely, that the greatest
objection is to placing the Boards under the con-
trol of the Commissioner of Education. Such a
change as is proposed would bring these Boards
under the control of one individual, and that indi-
vidual filling a position by political appointment.
If the Board of Regents could be substituted, for
the Commissioner of Education, the bill would be
vastly improved. In fact, the bill does not other-
wise read badly.
Dr. Schlicter: I also think this substitute would
be a good one and for the reasons just expressed
by Dr. Morrill. I am skeptical about giving too
much power to the State Board of Education, and
I say that because there seems to have been lately
68
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
a movement all over the country, on the part of
these Boards, seeking for more power.
Dr. Morrison : I move that the suggested amend-
ment, providing that the Board of Regents shall
be substituted for the Commissioner of Education,
in S. 304, be endorsed.
The motion was seconded, but was defeated by
vote of the committee, after lengthy discussion of
the bill and its possible effects by Drs. McGuire,
Reik, North, Hagerty, Lippincott, Hunter and
Davis.
Dr. Londrigan moved that the Welfare Committee
express its opposition to the entire bill — S. 304.
The motion was seconded and carried.
Report of the Executive Secretary
(Section 2)
Next, Mr. Chairman, I would like to report that
in response to a call from the Legislative Bureau
of the American Medical Association, I have filed
with each of the Senators and Congressional Rep-
resentatives from New Jersey protests against 2
bills now under consideration by Congress (1) An
Antivivisection Bill applicable to the District of
Columbia but announcedly intended as an enter-
ing wedge for similar legislation relating to the
states; (2) the Jones-Cooper Bill which consti-
tutes an attempt to reenact the old Sheppard-
Towner law. As indicating our relationship with
legislators, resulting from the plan of direct per-
sonal appeal in the name of the State Society, it
will interest you to know that out of our delegation
of 14 members written to, we received prompt an-
swers from 10 ; 1 of them replying by telegram,
and all of them expressing thanks for the infor-
mation supplied.
Dr. Dippincott: I think we should endorse the
the Secretary’s action in this matter, and trust
somebody will so move.
Dr. Conaway offered a motion endorsing the
Secretary’s action and instructing him to continue
opposition to the Antivivisection and the Jones-
Cooper Bills.
The motion was seconded and unanimously
adopted.
Executive Secretary’s Report
(Section 3)
At one of our sessions last year, we had under
consideration a form of health department blank
to be used by physicians in recording information
required by law to be made available to the
Crippled Children’s Division of the State Rehabil-
itation Commission at that time objections were
made to the several forms under consideration.
On December 4, Mr. Buch, the Chairman of
that Commission, called to see me for the purpose
of submitting a new record form. He has
endeavored to reduce the requirements to the
lowest limit, and the present proposition is
to utilize the customary Health Department blanks
for births and still-births, adding to such books of
blanks, in the front portion, several blank forms
to be used when necessary. On the regular blanks
would be printed a line directing attention to the
necessity for filling the special blanks whenever
there exist deformities that should be reported.
The special blank provides for recording the name,
address, date of birth, type of deformity, whether
under treatment or referred to other physicians
or surgeons, and the signature of the attending
physician. The Commission and the Health De-
partment would like to have immediate considera-
tion of this matter so that if approved the certi-
ficates can be prepared for new blanks about to
be ordered by the Department.
Dr. Ely: As Dr. Reik has stated, this matter was
before us a year or more ago and it seemed impos-
sible then to agree upon a satisfactory method of
making these records. I move that we approve of
the plan he has submitted today.
The motion was seconded and adopted.
Report of Executive Secretary
(Section 4)
The National Bureau of Economic Research, in
letters dated December 2, appealed to Drs. Sommer
and Morrison for information regarding medical
care on an insurance or contract basis, in New
Jersey. The Bureau asks: “(1) Do you know
of any hospitals or group clinics in your state that
are offering medical service to individuals or to
employers (for the benefit of their employees) on
a contract basis? The essence of the contract is
of course an agreement on the part of the hospi-
tal or clinic to furnish a certain type of service
during a stipulated period of time in return for
a fixed fee paid by the contract holder. (2) Do
you know of any corporations or associations of-
fering such service and arranging with medical
practitioners and hospitals to give the medical
service?”
A proper response to this request would neces-
sitate an investigation that would involve consider-
able time and labor for some person or committee,
and we submit the proposition for consideration.
Dr. Haggerty: I move the appoinment of a sub-
committee to consider this question and report
later to the Welfare Committee.
The motion was seconded and adopted. The chair
appointed Drs. D. Leo Haggerty, Chairman ;
Francis R. Haussling and Samuel A. Cosgrove.
Report of Executive Secretary
(Section 5)
At the last annual meeting of the State Medical
Society a great deal of time was devoted in the
general sessions and in sessions of the Section on
Ophthalmology, to discussion of the Workmen’s
Compensation Laws. The December issue of the
Journal carries one of the most instructive dis-
cussions of that subject that we have seen, and
the January issue will carry the papers and dis-
cussions that were associated with the appear-
ance at our convention of the medical represen-
tative of one of the large insurance carriers.
Our neighbor states, with compensation laws
more or less like our own, and with problems of
similar character to those that have arisen in this
state, have also been giving attention to this mat-
ter. The New York State Journal of Medicine of
November 15, 1930, presents us with an agreement
that has been made between the Medical Society
and the Compensation Carriers — an agreement
which seems to offer a solution for most of the
difficulties complained of. I have a copy of that
agreement at hand, but I would not claim to be
competent to say that it is applicable in all re-
spects to conditions in New Jersey. I would like
to suggest that it be immediately taken under
consideration by some one or some committee
competent to advise the Welfare Committee and
the State Society with reference to this matter.
Dr. Morrison: This is a matter that deeply con-
cerns the Medical Society of New Jersey and I
move the appointment of a subcommittee of 5
to study the documents that Dr. Reik is prepared
Jan., 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
69
to present, and to advise us as to their application
to New Jersey conditions.
Dr. John Hagerty: In seconding that motion I
want to say that I attended a meeting in New-
ark recently at which this same matter was dis-
cussed and I think that the New York agreement
is applicable to most of the conditions existing
here with reference to our Workmen’s Compensa-
tion Act. I will be glad to serve on that committee
if you think I can be of any assistance.
Dr. Lippincott: It is so unusual to have anyone
volunteer for work that I think we can assure
you, Dr. Hagerty, your offer will be accepted.
The motion was then unanimously adopted. The
chair appointed Drs. J. Bennett Morrison, Chair-
man; John F. Hagerty, H. B. Costill, Millard F.
Sewall and B. C. McMahon.
Dr.Reik: During the last 2 legislative sessions,
Dr. Leo Haggerty has looked after certain affairs
for the Welfare Committee, particularly by keep-
ing us informed of the exact status of legislation
pending in the General Assembly. Being required
to subscribe to the New Jersey Legislative News,
he has expended for such information the sum of
$25, for which amount he should be reimbursed.
A motion duly made and seconded authorizing
payment of this bill.
Dr. Morrison: I would like the Welfare Com-
mittee to submit to the House of Delegates of the
Medical Society of New Jersey, at its meeting in
June next, a request that this committee be given
permission to draft an amendment to the Medical
Practice Act giving us power similar to the Griev-
ance Committee, provided for in the New York law.
Dr. Morrison’s motion was seconded and unani-
mously adopted.
The meeting then adjourned.
Respectfully submitted,
Henry O. Reik, M.D.,
Secretary.
Woman’s Auxiliary
THE SOCIETY FOR THE RELIEF OP WIDOWS
AND ORPHANS OF MEDICAL MEN
OF NEW JERSEY
Edward J. Ill, M.D.
(An address delivered before the Woman’s Aux-
iliary of the New Jersey State Medical Society at
the Annual Meeting June 12, 1930.)
I am thankful to be able to present to you
some facts which should of necessity interest you.
If it is not for your personal benefit, you should
be aware how many doctors leave their families in
a destitute condition and how our society has been
able to relieve much real distress.
The Society for the Relief of Widows and Or-
phans of Medical Men of New Jersey has been in
existence for 40 years. It has 500 members. At
the annual meeting on May 14, the Treasurer re-
ported a Permanent Fund of $44,930. The income
from the Fund amounted to $2316.63. This in-
come may be distributed to such widows and or-
phans as in the opinion of the trustees is thought
wise. The trustees wish to help such as are in
need. It is not considered a charity by the trus-
tees but a right to which such widows and or-
phans are entitled.
I am asking you now to present to me the names
of such widows and orphans of members, who are
in need, so that the trustees may take such ac-
tion as they think wise to give some relief. It has
been most difficult to get the names of such as
are in need. A false modesty, or let us call it pride,
may be at the bottom. Let us remember that the
needy have a right to request aid.
During the past year we have distributed $850
to such widows. No doubt we could do better if
we knew to whom to send help.
It may interest you to know of a few instances
of which the trustees have been able to learn and
where they have given relief.
There is Mrs. S., the widow of a very active
former member of the State Society. He left her
with an income of less than $15 a week, and a
hopeful son of grammar school age. With the little
help we could give her, being an energetic woman,
she got along. Suddenly her son, after leaving
college, got sick with an incurable disease.
Then there is Mrs. W., left with 3 little children
and no help.
Mrs. N. was an old lady when she became a
widow. We helped to get her into an old ladies
home.
Mrs. V. was left with 6 children ranging from
2 to 15 years of age, after her husband had died
from pulmonary phthisis of some years standing
and during which time their little savings had
dwindled to almost nothing.
Mrs. T. had a husband, who had been sick and
helpless with chronic arthritis. For years he earn-
ed nothing, and we were glad to make him a loan
while he was living and then helped the widow
until such time as she could look out for herself.
Mrs. G. retired to the country. Two of her
half -grown-up children got sick with phthisis. We
were glad to help her.
Mrs. H. was left with 5 little children after Doc-
tor H. died from a long illness of heart trouble.
She certainly needed our help.
Dr. E. left a widow, well advanced in years. He
was an old man when he died. He had lost all
during his declining years when sickness prevented
following his occupation.
I might go on relating many more deplorable
instances. In 9 years we have distributed but
$4400. During this time we have also made loans
to sick doctors to the amount of $720. This, of
course, came back to us from the death benefits
but was soon returned to the widows as a gift.
You will be surprised to learn how many widows
are in immediate need of funds after the doctor’s
death. With the usual poor business ability of
our profession, no provision has been made for
any immediate help. Thus, a very busy surgeon
died within the year. There was not enough money
to pay the grocer. Our check came as a great
relief and we were glad to be able to send it
within a few days of the doctor’s death.
I am showing you what amount we have paid
out annually during the past 11 years.
Amount paid heirs of members each fiscal year
ending May 1: 1920, $4250.25; 1921, $1197.75; 1922,
$3856.50; 1923, $2430.50; 1924, $3956.00; 1925,
$4317.25; 1926, $5467.75; 1927, $2126.75; 1928,
$3617.25; 1929, $5633.75; 1930, $5307.75.
If your husband is not a member please pre-
vail on his becoming one. Please correspond with
me or the Secretary, Dr. Wm. D. Minningham,
18 Hedden Terrace, Newark, N. J.
I want to thank you for giving me a hearing
70
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
and am open to any questions you may want to
put before us.
I also want to express my appreciation to your
President, Mrs. Hunter, as well as Mrs. Clark,
Chairman of your Program Committee for their
kindness to me.
WINNING THEM OVER
At a meeting of the Secretaries of County
Branches of the Wisconsin Medical Society, held
at Milwaukee, March 1, 1930, the President of the
State Society, Dr. F. J. Gaenslen, said: “I am glad
to see that one of the subjects on the program is
that of the Woman’s Auxiliary. While I was not
keen about that some months ago, the more I
think of it, the more I feel it is going to be a
powerful influence in the formation of public
opinion regarding matters pertaining to medicine
and to public health in general.”
STATE AUXILIARY
The Woman's Auxiliary to the Medical Society
of New .Jersey will hold a luncheon meeting at the
Stacy-Trent Hotel, in Trenton, on Monday, Jan-
uary 12, at 1 p. m. Mrs. Walter Jackson Free-
man, of Philadelphia, will be the guest of honor
and there will be guests from the neighboring
states of Pennsylvania and Delaware. Mrs. Free-
man will outline plans for the meeting of the
National Auxiliary to be held during the session
of the American Medical Association in Phila-
delphia from June 8 to June 12. She will tell
the State Auxiliary how much depends upon it
in the line of hospitality.
Mrs. John Nevin, the President, will preside and
she will help formulate a program for our activities
during the meeting of our State Society at Asbury
Park the first week in June.
Please send acceptances promptly to Mrs. George
N. J. Sommer, 120 West State Street, Trenton,
New Jersey.
Bergen County
Reported by Mrs. Michael Sarla
The regular monthly meeting of the Woman’s
Auxiliary to the Bergen County Medical Society
was held in the form of a luncheon on December
9, at ‘‘Ye Chestnut Tea House” in Bogota with 23
members present.
Mr. and Mrs. B. C. Wooster, of the County Board
of Education, were our guest speakers.
Bridge was played during the remainder of the
afternoon.
Gloucester County
Reported by Mrs. Henry B. Diverty
The Woman’s Auxiliary to the Gloucester
County Medical Society had luncheon at the Wood-
bury Country Club November 17 at 1 p. m., under
the auspices of the American Homes Department
of the Women’s Clubs, to hear Dr. Ellen Potter,
Director of Medicine in the State Department of
Institutions of New Jersey.
On November 20 the Auxiliary met at the Wood-
bury Country Club at the same hour of the doc-
tor’s meeting, the president, Mrs. E. Downs, in
the chair: 14 members and guests were present.
Following the business meeting Mrs. James Hun- 1
ter, Jr., of Westville, ex-president of the State j
Auxiliary, gave a detailed report of her trip to
the Johnstown, Pa., Convention the week of Oc- j
tober G and stressed the efficiency with which it 3
was conducted. She also reported as 1 of 4 vice-
chairmen on the State Program Committee for
entertainment of the guests of A. M. A. Conven- J
tion to be held June 8 to 12, 1931, in Philadelphia.
Plans are well under way, under the very effi-
cient leadership of Mrs. Freeman, of Philadelphia.
After adjournment the doctors and Auxiliary were I
ushered into the dining room where a wonderful |
repast was served by our new chef at the Wood- 1
bury Country Club.
Hudson County
Reported by Anne Hetherington
The regular meeting of the Woman’s Auxiliary I
to the Hudson County Medical Society was held on I
November 14 in the Jersey City Y. W. C. A.
Announcement was made that on January 21, 1
in the Stacy-Trent Hotel at Trenton, an open 1
executive meeting will be held, followed by a t
luncheon at which the president, Mrs. John Nevin, 1
hopes to see a large representation from Hudson I
County.
The event of the day was a lecture on “Adult- I
Child Psychology” by Miss Flack, member of the I
Child Development Institute of Columbia Uni- |
versity. Miss Flack commended those present for
their interest in her subject, which is engaging -
almost universal attention. She explained the urg- I
ent need of a new psychology to solve the prob- I
lems of the modern parent and child since the
whole fabric of living has changed in the last 10 I
years. Instead of the old-fashioned home with its I
garden and attic play-grounds, we have the small I
apartment where the mother has a 24 hour con- fl
tact with the child. Irritability is the natural re- 1
suit of such emotional strain. Perhaps George I
Bernard Shaw had an over-burdened mother in
mind when he made the statement that the only
autocracy left in the world today is the home, I
where the worst tempered member always rules. 1
It is the purpose of the newer methods to lessen
difficulties of that hardest but most important job
in the world — raising a family. Psychologists are
opening the way to a better understanding of child
behaviorism and many believe environment to be
the strongest influence in human training. Scien-
tists differ on this score, some declaring the adult
to be 80% the result of heredity and only .
20% of environment, but since not much can be
done with heredity any way, the more plastic fac-
tor, environment, remains the hope of the race.
A social hour was enjoyed after the lecture.
The following new members wei'e welcomed:
Mrs. O. R. Blanchard and Mrs. E. J. Daly, of
Jersey City; Mrs. Joseph Londrigan, Mrs. H.
Broesner, Mrs.. J. Rosenkranz and Mrs. W. W.
Farr, of Hoboken; Mrs. H. Schwartz, North Ber-
gen; Mrs. William Eckert, Union City; Mrs. E.
Bailyn, West New York; and Mrs. Charles Larkey*
of Bayonne.
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
71
County Society Reports
ATLANTIC COUNTY
John Irvin, M.D., Reporter
The regular monthly meeting of the Atlantic
County Medical Society was held in the Blue
Room of the Chalfonte Hotel on Friday evening,
December 12, at 8.30 p. m., with 95 in attendance,
including Dr. George N. J. Sommer, President of
the State Society, and Dr. J. B. Morrison, Secre-
tary of the State 'Society.
The minutes of the previous meeting were read
by Dr. Joseph IT. Marcus, secretary.
Dr. Homer I. Silvers, president, called for re-
ports of the various committees.
Board of Censors by Dr. Clarence Andrews: The
applications of doctors who have just graduated
or Who have not been practicing for 12 months
will be held over for 12 months. This is no re-
flection upon the man himself, but is merely a
custom.
Public Health and Sanitation by Dr. W. Blair
Stewart: The matter of broadcasting was brought
up at the last meeting. Dr. Reik has been in-
vestigating that subject. A motion was passed
that the incoming president appoint a committee
to arrange for broadcasting of health talks over
WPG.
Dr. Stewart spoke of the Abell Bills now before
the state legislature to reorganize the state busi-
ness and the state budget. Dr. Stewart stated ob-
jections of the Board of Medical Examiners and
said he would like to see the society vote unani-
mously against these bills.
Dr. Sommer spoke about S. 262 which pro-
vides for putting all state funds in a budget sys-
tem, including all funds received from licensing
candidates. While the proponents of this bill as-
sure us that there will be no difficulty about
allowing funds for the prosecution of illegal prac-
titioners, there is nothing definite in the bill about
this matter. When one deals with politicians one
must not take anything for granted.
Dr. Darnall also spoke against these bills and
urged all who could to be present at a hearing
on the bills in Trenton.
A motion was unanimously carried that the so-
ciety go on record as opposed to Senate bills 262
and 304 and that a copy of the motion be sent
to our senator and assemblymen.
Dr. Morrison read a paper on the menace of
state medicine, explaining its present status and
asking all to concern themselves in order that we
may find a relation satisfactory to the public and
to the profession.
Dr. W. P. Conaway spoke about a notice he had
received from the Narcotic Department of the
Government. This notice stated that if the nar-
cotic tax is not paid medical men are subject to a
fine of $2000 or jail for 5 years. Previously the
fine was 75% of the amount of the tax. He sug-
gested that steps be taken to find out what this
means. Dr. Stewart replied that he has already
written to the authorities for an explanation.
Dr. J. H. Marcus read a letter from another col-
lection agency which desires to enter into rela-
tions with the society. The communication was
laid upon the table.
A letter of appreciation was received from the
Atlantic Visiting Nurses’ Association.
Dr. Marcus also spoke about the collection of
dues. Out of 130 members, only 35 have paid
their dues. The official list closes January 25,
and those who are not paid up before that time
will not have their names listed and will not re-
ceive their Journal.
Dr. Silvers introduced the speaker of the even-
ing, Dr. John Deaver, who read an interesting
paper on “The Acute Abdomen”. Discussion fol-
lowed by Drs. Stewart, Senseman, Scanlan, All-
man and Deaver.
Atlantic City Hospital Staff
Joseph H. Marcus, M. D., Secretary
The stated monthly meeting of the Atlantic
City Hospital Staff was held November 2 8 in the
Nurses’ Auditorium, with Dr. David B. Allman
presiding.
The program presented was that of the Medi-
cal Service, Dr. Clarence D. Andrews, Chief, and
Dr. Hilton S. Read.
Dr. Read presented a survey of the months of
August, September and October; 169 patients
being admitted, of whom 90 were males and 79
females.
Dr. J. V. Reeves, resident physician, reported an
interesting case of “Ruptured Abdominal An-
eurysm”. C. P., aged 32, male, colored, was ad-
mitted complaining of pain in the epigastrium,
coughing and vomiting of blood (?). Father died
of carcinoma, 5 yr. before, but further than this
no hereditary taint discoverable. Onset of trouble
3 days before admission. Went on a “drunk’1’ and
stayed under the influence of alcohol for 2 days;
then began to feel weak and this weakness was
accompanied by distress in the epigastrium. This
tormina increased in severity, giving a severe
burning sensation in the region of the stomach.
On the same day he commenced to vomit, which
continued until his death. His appetite remained
good but he could retain no food. On the day
of admission vomited about a pint of dark red
blood, which gave him great relief. He thought
that he passed some blood in his stools on several
occasions before admission. Pulse rapid, irregu-
lar and weak; B. P. 105/70; temperature 102.5°;
heart, slight enlargement to left; aortic area of
dullness slightly widened; no bruit, thrill or
murmur heard. Patient had a hacking cough
productive of a slight blood-tinged expectoration.
The lungs were negative except for roughened
breath sounds and a few moist crackling rales
at the left base posteriorly.
Distinct tenderness and slight distention in the
upper abdomen. Blood count 4,200,000 red cells
and 9 000 leukocytes of normal differentiation.
Wassermann and Kahn tests negative. Urine of
no significance, and deep reflexes normal.
Condition grew progressively worse; cough
more annoying; pain more severe in the epigas-
trium; vomited several times during the first day
and pulse rate dropped from 124 on admission
to 60; temperature remained 102°. On the second
day vomiting continued and he had what was ap-
parently a pulmonary hemorrhage of about 3 oz.
blood. There developed both a pericardial and
pleura] friction sound in the left axilla, with con-
siderable bogginess of the left base posteriorly
but no evidence of fluid or consolidation.
The patient was being treated for a probable
alcoholic gastritis and pneumonitis. On his third
and last day after admission he had apparently 3
pulmonary hemorrhages of 3 oz. each following
severe attacks of coughing and vomiting. His
symptoms grew worse from 3 p. m. to 2 a. m.
when he died rather suddenly, remaining con-
2
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
scious to the end; temperature fell gradually from
102° to 97°, and pulse jumped from 75 to 155,
and interceptability in his last hours.
Autopsy. The left pleural cavity was literally
filled with clotted blood and the lung greatly com-
presed. Tracing the descending aorta a clot
about the size of a baseball was found just above
the diaphragmatic hiatus, removal of which dis-
closed a hole in the aorta about 2 cm. in diameter.
The stomach was entirely normal. Anatomic diag-
nosis— ruptured aneurysm of descending thoracic
aorta.
The chief mistake in diagnosis was brought
about by paying too much attention to his recent
history. With the knowledge of gastric insult
from excessive use of alcohol in the preceding few
days, and the main symptoms abdominal on ad-
mission, it was hard to lose sight of this possi-
bility when the signs and symptoms persisted in
the epigastrium and became more acute even as
new signs made their appearance in the thorax.
It is sufficient lesson that although a history is
indispensible in making many diagnoses it may
be at other times very misleading.
Dr. Moore presented the following case of
“Tetanus”. C. D., colored female, aged 58, ad-
mitted because of stiffness involving her jaws,
legs and back and twitchings of her arms. Re-
called no childhood diseases. In 1904, sustained
a dog bite on her left ankle and has been subject
to intermittent periods of ulceration of that area
since that time. She last felt very well August 4,
after which time she was subject to stiffness of
her neck, back and extremities. On August 5 she
worked at home ironing clothes all day but that
evening became somewhat worse and called in a
physician. She noticed on August 6 that her
jaws were becoming stiff and she had some diffi-
culty in eating, and so remained at home in bed
until August 10, at which time, being subject to
more marked rigidity of the jaws, legs and back
and associated muscular contractions in her
upper extremities, she was admitted to this hos-
had been active at the beginning of the illness
pital. The ulceration on her left ankle be-
came swollen and inflamed at the time she
noted the stiffness. On admission she suffered
from urinary incontinence but often before she
had been subject to this condition. Her bowels
were normal and her mentality unimpaired.
Observation revealed sudden contractions, tonic
in type, involving the flexor muscles of the upper
extremities, occurring at irregular intervals and
seemingly painful. Tetanus was the diagnosis
made upon admission and immediate admin-
istration of tetanus antitoxin was begun. It
became necessary to relax this patient before in-
traspinal administration was possible. Intra-
venus sodium amytal (9 c.c.) was given and re-
laxation obtained except for the legs and spine.
A cisterna puncture was successful and 10,000
units antitoxin were administered. The next day
an order was written for 10,000 units every 6
hours day and night, to be given intravenously,
and the following day we gave in addition 20,000
units into the cisterna. Because of impending
dehydration, 500 c.c. of 5% glucose in normal
saline were given intravenously. August 14 she
was able to open jaws somewhat further and
liquids by mouth were given. This was the first
day, 4 days after admission that any appreciable
improvement was evident. From day to day fol-
lowing the improvement in the muscles of the
jaws there was a gradual general improvement
and on August 30 toxin therapy was discon-
tinued.
Dr. Lucas, resident physician, detailed the fol-
lowing case of “Pernicious Malaria”. Mr. and Mrs.
J. R., aged 53 and 48 respectively, died from a
malignant infection of malaria, within 24 hours
after admission to the hospital. Family history
was negative, and the personal histories had no
bearing on the present conditions except for the
fact that they never previously had malaria and
were never in the South until this fall. At onset
of present illness they were just completing a
motor trip through the South. Just 11 days
before onset they spent a night in a mosquito in-
fested community in the Everglades.
Onset of illness occurred 5 days before entering
hospital and was ushered in by malaise, head-
ache chilliness and coryza anorexia. Within 2
days they were suffering from chills and sweats
at irregular intervals. By the fourth day the
man developed jaundice of rather marked degree.
He complained more of headache and generalized
muscular pains especially of the back and neck
muscles. The woman had more gastro-intestinal
symptoms; abdominal cramps, nausea, vomiting
and diarrhea. On admittance they were prac-
tically moribund. The man was in medical shock;
delirious, skin cold and clammy, pulse rapid and
irregular, and it was impossible to measure blood
pressure. He was markedly jaundiced, and ex-
amination revealed an enlarged spleen, the lower
border of which could be palpated 2 finger-
breadths below costal margin on anterior axil-
lary line. Liver not palpable.
The woman was extremely toxic, and assumed
the position in bed of one suffering from severe
abdominal pain; legs flexed on the abdomen and
she made continuous pressure over the epigas-
trium with her hands. She was rather obese. It
was impossible to palpate any mass in her abdo-
men. She was not jaundiced.
The man had a leukocyte count of 21,000 with
77% polymorphonuclears. The woman -also had
21,000 white cells with 92% polys in differential
count. Signet-shaped malaria parasites were
present in enormous numbers in blood smears
from both patients.
Treatment of the man consisted in measures to
combat shock and provide cardiac stimulation.
The woman was given quinin hydrochloride in-
tramuscularly every 6 hours, and the same
amount by mouth every 3 hours. The man died
14 hours after admittance; never reacted com-
pletely from shock. The woman died 22 hours
after admittance. Necropsy was performed on
the man and the spleen was 3 times normal size.
Dr. Robert A. Kilduffe demonstrated the pres-
sence of malaria parasites by microscopic photo-
graphy in the case reported by Dr. Lucas.
Dr. Clarence L. Andrews, chief of the Medical
Service, presented the report of the Medical Ser-
vice, commenting on each of the 32 deaths during
his service period, and comparing autopsy records
with ward diagnoses.
Dr.- Theodore Senseman presented a case of
“Spina Bifida” in an infant upon whom he had
operated some weeks before. The progress of the
baby and the site of operation were both highly
satisfactory, and there were no signs of increased
intracranial tension. The prognosis was indeed
excellent.
Pine Rest Sanatorium
Harry Subin, M.D., Reporter
The regular monthly meeting of the Staff of
the ine Rest Sanatorium was held at the insti-
tution on Thursday evening, December 11. The
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
73
minutes of the previous meeting were read by
the recording secretary, and accepted without
correction.
The scientific portion of the meeting was open-
ed by Dr. Fish, who demonstrated the method of
outlining Kronig’s Isthmus by palpation, percus-
sion and auscultatory percussion. He pointed out
that the narrowing of the field of resonance is due
to limitation of movement of the diaphragm on
that side.
The paper was opened for discussion by Dr.
Hudson, who believed that Kronig’s Isthmus
is not narrowed until scar tissue forms, and is
of no value as a sign in incipient phthisis.
Doubt as to reliability of the palpatory method
of outlining the limits of Kronig’s Isthmus was
expressed by Drs. Kaighn anc. Allman.
Those present were Drs. Hudson, Kilduffe, Mar-
cus, Allman, McGeehen, Fish, Pennington, Subin,
Nickman and Mr. Conover.
BERGEN COUNTY
C. H. Dittwin, M.D., Reporter
The regular meting of the Bergen County Medi-
ical Society was held at Englewood Hospital on
the evening of December 9. Dr. Edward W.
Clarke presided. In addition to about 6 0 mem-
bers of the society there were a great many stu-
dent nurses of the hospital present. The minutes
of the last meeting and also of the Executive
Committee meeting were read and approved.
A motion was regularly passed recommending
that the physicians of the society charge a flat
rate of $6 for diphtheria immunization.
Dr. Huff reported for the Educational Com-
mittee, which consists of Drs. Wolowitz, chair-
man, Huff and Black, appointed in the interim
since the last meeting. Rutgers College courses
are again being offered, and after a quick survey
the committee believes the most popular course
to be in obstetrics and office gynecology.
The secretary mentioned a meeting of the State
Compensation Committee in Newark to consider
different phases of the compensation laws; Dr.
G. W. Finke represented Bergen County.
The question concerning Dr. F. Haagen was
presented to the society. The Executive Com-
mittee at one of its previous meetings requested
an investigation of this man by the federal au-
thorities. A week ago the announcement came
out on the front page of the Bergen Evening
Record that he admitted being a drug addict and
would go away for treatment. Dr. A. Liva, Presi-
dent of the State Board of Medical Examiners,
suggested that the society write a letter stating
these facts, to serve as a complaint, so that the
Board might hold a hearing on the revocation of
his license. After some discussion Dr. Littwin’s
motion was passed that this matter be referred
to the committee on Public Relations, for a report
at the next meeting.
Then followed a long and excellent scientific
program prepared by Dr. Dittwin as follows:
Immunization of Measles with Convalescent
Serum, Dr. George Heller, of Englewood.
Squint in Children, Dr. Raymond Meek, of New
York.
The School Physician and the School Health
Program, Dr. A. G. Ireland, of Trenton.
Pneumonia in Children, Dr. Charles H. Smith,
of New York.
CAMDEN COUNTY
Robert Gamon, M.D., Reporter
The regular monthly meeting of the Camden
County Medical Society was held in the Camden
City Dispensary Building, December 2, with Dr.
E. G. Hummell, Vice-President, in the chair.
The society was honored by attendance of the
President of the State Society, George N. J.
Sommer, of Trenton, and (Secretary J. B. Mor-
rison. Dr. Sommer spoke briefly, emphasizing
the importance of a strong Woman's Auxiliary
and its relationship to the county society. He
also emphasized the importance of our society
taking part in the Post-Graduate Courses offered
by Rutgers University and the Medical Society of
New Jersey.
Dr. Morrison read a very timely paper on the
much talked of subject of state medicine.
Both speakers were most cordially received.
The regular Scientific Program followed .
“Sinusitis'’, Earl S. Hallinger (by invitation.)
Discussion opened by O. R. Kline.
“Status of Present Day Treatment of Pneu-
monia”, T. K. Bewis. Discussion opened by E. B.
Rogers.
“The Management of the Asthma Patient ”
Geo. P. Meyer.
Dr. D. F. Bentley, Jr., historian of the society,
was given a rising vote of thanks for his contri-
bution in the form of an “Historical Sketch of
the Camden County Medical Society” and its
members which is appended to the newly pub-
lished Constitution and By-Laws of the Society.
Communication from the President of the So-
ciety, Dr. W. J. Barrett, indicated he would be
present at the January meeting of the Society.
Dr. Wilmer Kruzen, Jr., Assistant Dean of
Temple University Medical College, was a guest
at the meeting, and by invitation discussed the
papers of Drs. Hallinger and Lewis.
Dr. A. G. Kinney, 249 Woodlawn Terrace, Col-
lingswood, N. J., was elected to active member-
ship.
Drs. H. P. Coxon, of Stratford, N. J., and Samuel
Rosen, 109 N. 27th Street, Camden, were pro-
posed for membership.
A special committee was appointed by the
president to consider advisability of the Camden
County Society taking part in the annual Post-
Graduate Courses.
The discussion and interest in the meeting was
active.
ESSEX COUTY
Frank W. Pinneo, M.D., Secretary
The plans of our Maternal Welfare Commission
are complete for the course in obstetrics. Here-
with please find their announcement.
You are offered a special course of lectures,
with manikin demonstrations, conducted by the
teaching staff of Obstetrics and Gynecology of
Columbia University land Sloane Hospital for
Women. We believe this course offers an unusual
opportunity in obstetrics for our members.
Tickets will be issued to those who subscribe,
remitting $10, for the course of 6 lectures, to be
held at the Academy of Medicine, 91 Lincoln
Park, Newark, 4.3 0 to 6 p. m„ scheduled as fol-
lows:
Wednesday, January 14, Pre-natal Care and
Management of First Stage, Dr. B. P. Watson.
74
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
Wednesday, January 21. Forceps Delivery, Dr.
W. E. Caldwell.
Wednesday, January 28, Breech Delivery:
Version, Dr. W. E. Studdiford.
Wednesday, February 4, Fetal Injuries and
Neonatal Pathology, Dr. E. S. Coler.
Wednesday, February 11, Antepartum Hemor-
rhages, Dr. H. Halstead.
Wednesday, February 18, Pelvic Floor Injuries:
Their Prevention and Repair. Management of
Puerperium, Dr. C. E. Caverly.
Eye, Ear, Nose and Throat Section Academy of
Medicine ol' Northern New Jersey
E. LeRoy Wood, M.D., Secretary
A very interesting meeting of the Eye, Ear,
Nose and Throat Section of the Academy of Medi-
cine of Northern New Jersey was held on Monday
evening, November 10, under Chairman J. Wal-
lace Hurff.
The paper of the evening was on “Detachments
of the Retina and the Gonin Operation1’, read by
Dr. Mark J. Schoenberg, of New York City. He
related that up to advent of the Gonin operation
nothing promising was known about detachments
of the retina, while at the present time there is a
definite favorable prospect in a number of cases.
He estimated that of all cases of detachment of
the retina, only 40% are suitable for operation,
and of those operated on the results are good in
50% of the cases. The operation resulted from
the fact that in the study of beginning detach-
ments a hole or tear in the retina could often be
seen, and the thought occurred that perhaps if
that hole or tear could be closed with a cautery
the process might be arrested. Local anesthetic
is used, holocainbutyn, but never cocain, because
a clear cornea allowing fundus inspection is
essential. An incision is made in the cornea at
a point located over the retinal hole. Expose
sclera, dry and clean sclera, stop oozing to avoid
blood in the vitreous. Incise medially with Grade
knife, pass cherry-red cautery through incision,
and through retina into vitreous. Then the cau-
tery is withdrawn, catching the retina, pulling it
out and anchoring it to the wound. The after-
treatment is atropin, bandaging of both eyes, and
bed for 8 days. Have the patient rest so that
the operated area is in a dependent position and
the vitreous lies upon it. Do not look at the eye
for 6 days unless the patient has pain. Conjunc-
tival sutures are removed the eighth day and a
cathartic given; then diet for 8 days more. There
is danger of hemorrhage from the sixth to ninth
day; greatest when walking around.
Dr. Elbert S. Sherman reported the absorption
of a large traumatic opacity of the lens. When
he first saw the patient, a slender grass wire had
perforated the eye 4 days previously and vision
was only fingers at 1 foot. There was a large
opacity in the posterior part of the lens cortex.
One month later vision was 20/30 and the opacity
thinner; 5'A months later the vision was 20/20
without correction and the opacity had completely
disappeared and was not visible even through
the slit lamp. Dr. Sherman said that small opaci-
ties may absorb but he had never seen such a
large one disappear. He pointed out the lesson
that one should not be hasty in giving on opinion
as to the percentage of disability, until sufficient
time has elapsed.
Dr. Wallace Pyle, of Jersey City, made a fur-
ther report of a case he first presented in 1924.
The patient first seen by him in November, 1923,
and then 4 months old, had a profuse discharge
of pus from each eye and a false membrane on
both lids which presented a diagnostic problem
after diphtheria, gonorrhea and Vincent’s angina
were ruled out. Opinions of eminent consultants
were secured and the diagnosis of the rare con-
dition— “Recurrent Membranous Conjunctivitis”
— finally agreed upon. In February 1926 the eyes
were quiet, the lower lids free, with a marked
growth from the upper lids. On November 1,
19 30, neither eyeball was inflamed, there was no
membrane and the lids looked like an old trach-
oma. There were marked polypoid, peduncu-
lated growths from both upper lids, which ap-
peared to be easily removable but surgical assist-
ance was refused.
Dr. Linn Emerson, of Orange, reported seeing a
patient with “Double Symmetric Ring-like Catar-
act with Clear Central and Outer Portions and
Preservation of Good Vision”.
Thirty-two members were present. The meet-
ing adjourned at 10.50 p.m.
GLOUCESTER COUNTY
Henry B. Diverty, M.D., Reporter
A most interesting meeting of the Gloucester
County Medical Society was held December 18 at
the Oak Valley Country Club, near Woodbury
Heights, entertained capably by Carterer McGar-
rity. The following members were present: Drs.
S. F. Ashcraft, of Mullic.a Hill; M. F. Lummis, of
Pitman; James Hunter, Jr., R. K. I-Iollinshed,
Edwin R. Ristine, of Westville; C. F. Fisler, of
Clayton; E. E. Downs, J. Harris Underwood,
Harry Nelson, C. A. Bowersox, of Woodbury; A
B. Black, of Mickleton; William and Charles Ped-
rick, of Glassboro; B. A. Livingood, of Swedes-
boro; O. R. Wood, of Paulsboro; H. W. Stout, of
Wenonah and I. W. Knight, of Pitman. Guests
wer Dr. Masineo, of Philadelphia; Dr. James L.
Gray, of Pitman; Professor Clovis, of Rutgers
University; Dr. J. Claude Foster, of Westville, and
Dr. Amos Underwood. Dr. Corson, of Bridgeton,
and Dr. Church, of Salem County, were present
as delegates.
The essayist of the evening was Professor John
H. Gunther, M.D., D. D. S., assistant professor of
anatomy at the University of Pennsylvania Den-
tal School, and whose subject was “The Relation
of Mouth Infections to the Manifestation of Gen-
eral Disease.” This important subject was finely
illustrated by lantern slides.
HUDSON COUNTY
Harry J. Perlberg, Secretary
The Hudson County Medical Society held its
monthly meeting December 12 with Dr. J. M.
Cassidy presiding.
The minutes of the last meeting were accepted
as published in the bulletin.
The Board of Censors reported favorably upon
the following applicants: Herman M. Jaffe, Con-
rad M. Bahnson. J. L. Mathesheimer, and Otto H.
Mustermann, and all were elected.
Dr. Cassidy spoke of the passing away of Dr.
J. H. Commorato, and requested that a large dele-
gation of members attend the services as a last
tribute of respect to his memory.
The following Committee on Post-Graduate In-
struction was appointed by the president: L. C.
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
75
Lange, Chairman; Thos. White, R. L. Ballinger,
George Gingsberg and A. E. Jaffin.
In reference to the Antidiphtheria Campaign,
the president stated that he had a conference
with Dr. Salmon, who had assured him of close
cooperation between the Board of Health and the
Hudson County Medical Society.
Dr. Cassidy stressed the laxity of members of
the various committees and called upon them to
fulfill their obligations.
A symposium on Genito-Urinary Disease was
then held.
Dr. C. L. DeMerritt, whose subject was “Ure-
thral Conditions in their Relation to Sexual Dis-
turbances”. Sex failure is defined as an involun-
tary failure to perform the sexual act. It is to •
be sharply defined from sterility, as the latter is
a failure to discharge live spermatozoa, and in
no way denotes importance. Among the causes
of sterility are; (1) urethral causes, as after pros-
tatectomy or with a tight stricture, where it is
conceivable that the seminal discharge might be-
come reflux into the bladder; (2) central nervous
system lesions, with involvement of the nervi eri-
gentes; (3) hypofunctiOn of the testicular cells;
(4) asthenia and debility; (5) psychic causes.
Dr. DeMerritt then proceeded to give a brief
but adequate review of the anatomy of the male
generative organs, with special reference to the
urethra, and a description of the sex lesions of
the urethra.
(1) Anterior urethral canal, (a) Malformations.
Epispadias is so rare as to warrant no attention.
Hypospadias — the opening is usually in the un-
dersurface of the gland, and the lesion per se
seldom if ever causes impotence or sterility, (b)
Urethritis. In the acute stages, the condition
causes impotence. In the chronic stages, the pa-
tient is potent and desirous of sexual intercourse
long before being cured, unfortunately, (c) Stric-
ture of itself causes no change, but when associat-
ed with urethritis, as is usual, impotence is the
rule, (d) Chordee if sufficiently great may inter-
fere with the sexual act and require surgical re-
lief.
(2) Posterior urethral canal. Here is the
usual site of trouble in impotence, and here the
vast majority of causes are to be found in dis-
ease and dysfunction of the verumontanum or
crest. Dr. DeMerritt here outlined the anatomy
and known physiology of the crest. It ’S a highly
glandular, non-erectile mound of tissue on the
posterior aspect of the prostatic portion of the
urethra, which changes slightly on erection. It
is regarded by some as the trigger of the sexual
gun, timing the moment of discharge.
Diseases of the Crest
(1) The congested crest. Common causes are
urethritis and coitus interruptus. Masturbation
becomes of concern only where clerical cure has
been attempted, with usual severe psychic results.
The crest in this type is red, congested, bleeds
easily and may have polypoid changes or excres-
cences. The complaint is usually early ejacula-
tion, before or immediately upon intromission. It
is especially common in middle-aged bachelors or
widowers who are continent before remarrying.
Treatment consists in the urethroscopic applica-
tion of caustics, and gives excellent results. The
procedure is to first clean up the field, apply car-
bolic to the entire crest; 5-10 treatments are given
once or twice a week, with fine results. Carbolic
is better than silver nitrate. While not so good
for diagnosis, the open instrument is better than
the air or water distention instruments for treat-
ment. In addition to local treatment, moderate
exercise, especially walking, is prescribed, with
attention to general hygienic measures.
(2) The anemic crest. With this type the out-
look is poor. Local treatment gives poor results
and attention to general hygienic measures seems
to offer the best chance. It is probably true that
the anemic crest does not follow the congested.
Its etiology is indefinite.
Dr. E. J. Daly talked on “Injuries to the Urinary
Tract Through Outside Violence”. The urinary
tract, except the urethra, although quite well pro-
tected by the bony skeleton and heavy muscula-
ture, is nevertheless subject to injury from out-
side forces, the result of falls, kicks, or squeezing,
which produce contusions and lacerations; or
pointed objects such as knives and bullets, which
produce penetrating wounds. The damage done
is not always in proportion to the force applied
and may be limited to the urinary tract, or com-
plicated by injury to other organs. Most cases we
have seen have been of the contused and lacer-
ated type. For convenience, we will divide our
field into upper and lower urinary tract.
In the upper portion we have the kidneys, renal
vessels, and upper ureters. Fortunately for the
patient, and also for the surgeon, we usually find
only one side involved. The kidney is injured by
being forcibly thrown against the spine or ribs,
or the blow being transmitted to it through the
muscle wall. In penetrating wounds, the object
passes directly into or through the kidney. The
resulting trauma may vary from a slight sub-
capsular contusion to multiple lacerations or com-
plete maceration of the organ. Where only a
slight contusion is present, there is an oozing
of blood which remains beneath the true capsule,
but, if the capsule is torn, will spread out into
the perinephritic tissue. The bleeding is usually
slight, ceases spontaneously, and healing is ac-
complished by absorption, or formation of fibrous
tissue. Where the injury is more severe and the
parenchyma is lacerated, with considerable
hemorrhage into the perinephritic fat, the same
process of healing may take place; but it is in
this type of case where secondary infection is
prone to occur, either hematogenous or directly
from the kidney or nearby bowel. Then we are
confronted with a perinephritis which develops
in the ensuing few weeks, or a destroyed kidney,
the result of a diffuse pyelonephritis, which mani-
fests itself some weeks or months later. If the
injury extends into a calyx, it permits escape of
urine and the above conditions develop more
readily. Extravasation of blood and urine al-
though somewhat limited by attachment of the
peritoneum to the posterior abdominal wall, tends
to burrow downward, and may extend into the
true pelvis. If the peritoneum has been torn,
it will enter the peritoneal cavity. These cases
are serious, not always because of hemorrhage,
but because of the devastating effect of the ex-
travasated urine.
Injuries to the upper ureter occur with in-
juries to the kidney; the major portion is so well
protected and fixed that it is rarely injured by
external forces; penetrating objects have caused
complete division and lacerations have resulted
from falls.
Where the patient's condition is not too alarm-
ing there is much to be gained by expectant treat-
ment, for when operation is indicated, nephrec-
tomy is either necessary or seems the most
rational procedure. I feel that a kidney that can be
left in will be a better kidney if left undisturbed.
76
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
During the period of observation, shock is com-
bated with heat, clysis and morphin. Pulse and
temperature should be recorded at hourly inter-
vals. Frequent palpation will reveal any in-
creasing tumor or evidence of intraperitoneal irri-
tation. These are all guides as to the necessity
of surgical intervention. When operation is in-
dicated, it is usually within 48 hours.
As to the future of these kidneys avoiding op-
eration, many of them seem to go along without
further trouble. Others develop a pyelonephritis,
or hydronephrosis, and are prone to be the seat
of calculus formation.
Lower tract. The bladder is more susceptible
to injury if distended, because in the collapsed
state or containing only a small amount of urine
it is well protected by the bony pelvis, while, if
distended, a portion of it is only protected by the
less rigid abdominal wall, and is also more sub-
ject to a greater hydrostatic pressure. Injuries
may be classified as contusions, lacerations and
perforations. Lacerations and perforations may
be either intraperitoneal or extraperitoneal, and
both conditions are serious, one because of the
escape of urine into the peritoneal cavity, and the
other because of extravasation into the pelvic
tissues, perineum, and abdominal wall. In our
own cases, most of the bladder injuries have been
extraperitoneal and associated with fracture of
the pelvis; damage to the bladder being longi-
tudinal tears or perforations by bone fragments.
Injuries of the bladder should be diagnosed
and proper treatment instituted as quickly as
possible. Here, we cannot carry out expectant
treatment with the same degree of safety as in
injury to the kidney. The symptoms of rupture
or perforation of the bladder are: History of in-
jury with sudden pain in the bladder region, blood
in the urine, desire to urinate but inability to do
so. Shock is .present; more so in cases accom-
panying fracture of the pelvis. In the intra-
peritoneal type, seen early, palpation may not dis-
close any particular evidence. This is very im-
portant in intoxicated persons, with intraperi-
toneal rupture. When seen late there is evidence
of peritonitis. In extraperitoneal rupture, there
is rigidity, fullness and tenderness over the supra-
pubic region extending laterally and into the peri-
neum. Catheterization as an aid to diagnosis is
valuable, but dangerous, and is not infallible. It
should be carried out under most careful asepsis
and one should be prepared to follow with opera-
tion in a very short time, if such procedure is
found necessary. The same may be said for cys-
toscopy.
The diagnosis having been made, operation
should not be delayed. Where intraperitoneal
rupture is suspected, the peritoneal cavity should
be opened through a low midline incision. The
wounds in the bladder, if jagged, should be trim-
med, and closed with at least a double row of
sutures. The escaped urine is mopped out, and
the abdominal wound closed in layers. A large
catheter is then passed through the urethra and
anchored in place.
For extraperitoneal ruptures, the usual supra-
pubic approach is made, and the bladder ex-
posed. Considerable bleeding is sometimes en-
countered, springing from torn pelvic bladder
vessels. The rupture or perforation is usually
found on the anterior aspect of the bladder, and
frequently extends into the roof of the posterior
urethra. The wound should be closed with a
double layer of plain catgut, and the bladder
drained through a suprapublic tube. The pre-
vesical bleeding can be controlled by gauze pack-
ing. Where the posterior or bulbous urethra has
been crushed, it is advisable, while the bladder is
open, to do a retrograde catheterization, leaving
the catheter in situ.
As to the care of a fractured pelvis, the appli-
cation of casts or slings does not seem very prac-
tical. Osteomyelitis, invariably develops and
sequestra of bone either work their way through
the skin or are removed. Bone healing, although
slow, is usually in the end quite satisfactory.
Urethra. The urethra may be injured by falls,
crushing the bulbous or membranous portions
against the pubic arch, cutting objects, gunshot or
bullet wounds, or circular pressure applied to
the penis. The most common cause is falling a-
stride some firm object such as a rail or beam;
this results in a contused laceration of the bul-
bous or membranous urethra. Gunshot wounds
usually involve the rectum or bladder, and may
carry away a considerable portion of the ure-
thra. Cutting objects cause wounds ranging from
lacerations of the urethra .and corpus spongeosum
to amputation of the penis. Circular pressure
from rings, rubber bands and iron bolt nuts, cause
interference with the circulation. The result de-
pends on the length of time the constriction is
present, and varies from a contusion to gangrene
of the distal portion.
Treatment of wounds of the urethra consists of
approximating the divided ends and diverting the
urine from the wound. In the less severe cases
this is readily accomplished by an indwelling
catheter over which the ends of the urethra are
approximated. When there is only slight injury
an indwelling catheter may be the only treat-
ment necessary. In cases of contused lacerations
of the perineal urethra, external urethrotomy
should be done. If the proximal end of the
urethra cannot be located, a suprapubic cystot-
omy and retrograde catheterization is necessary.
Dr. 8. R. Woodruff. “Radiographic Delineation
of the Urinary Tract by Means of the Intravenous
Injection of Uroselectan; A study of its Relative
Value as Compared to Retrograde Urography”.
Delineation of the urinary tract by utilizing the
secretory power of the kidney through the intra-
venous injection of a substance that would be
excreted in sufficient volume and be of sufficient
radiographic value, has long been sought as the
ultimate in urographic diagnosis. In 1923, the
first attempt was made by Osborne, Sutherland
Scholl and Rowntree who injected solutions of
sodium iodide of various strengths. The results
were not particularly noteworthy. There is at
present considerable discussion as to priority in
the application of the present uroselectan, and as
practically all the preliminary work has been
done in Europe, we do not feel that our knowl-
edge of conditions allows us to criticize or extol
in any particular direction. From our observa-
tions of such an important matter as this we
would draw attention to the splendid work done
by Professors von Lichtenberg and Binz and Drs.
Rath and Swick. At the Post-Graduate we have
been particularly fortunate in obtaining uroselec-
tan through the courtesy of von Lichtenberg and
this chapter is devoted solely to a consideration
of our results.
Uroselectan is an organic iodin combination
and its formula is still under observation and
likely to change, so that its exact chemical com-
position makes little difference at this time. It
is very soluble in water, neutral in reaction, and
practically 90% will be excreted (by the kidneys
within 8 hours. Some of the historians say that
it is non-toxic and that absolutely no reactions
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
77'
fallow its use. Our experience leads us to be-
lieve that this is not always true for we have
noted urticaria, generalized erythema of the
skin, and in 1 case, nystagmus, incoherence of
speech, and temporary unconsciousness.
We view, with considerable alarm the expect-
ancy of the general surgeon and internist who
believe that they will now be able to diagnose all
genito-urinary diseases, particularly those of the
kidney, without use of the cystoscope or urolo-
gist, and we feel that a crop of unfortunate, sur-
gical mistakes is about to be harvested. The
value of intravenous pyelography is tremendous
and unmistakable but its use should be limited
to those with experience in evaluating the results
obtained. Not the least of its value lies in the
fact that it is practically a most excellent test of
renal function, for in the normal kidney it is
quite usually to be found in the renal pelvis if a
roentgenogram is taken in 5 minutes after the
injection, while in those kidneys diseased or al-
tered in their functional capacity in any way,
delay or positive non-appearance of the material
is the result. Patients with moderate destruc-
tion of renal function in 1 kidney will show a
corresponding lengthening of appearance time
and insufficient filling of the renal pelvis. Where
both kidneys are damaged, one might even hesi-
tate in using the material unless it be desired to
do so from a functional standpoint. Some of our
cases were especially fitted for this type of diag-
nosis while others were done simply as a routine
procedure. It is in some peculiar conditions
found in urology that . intravenous pyelography
will be of its greatest value. Where one or more
ureters have been transplanted and ureteral ori-
fices are not available to catheterization we have
no other diagnostic means. In children a fertile
field will no doubt be found for this type of diag-
nostic procedure. In those cases where some
physical, mental or anatomic condition makes
cystoscopy either impossible or not advantageous,
delineation by this type of procedure will be of
immense -value.
One of our chief criticisms has been that one
has absolutely no control over the result after giv-
ing uroselectan. The radiographic exposure may
or may not contain anything of a diagnostic value.
Our principal objection is that the results are by
no means uniform. One may go through the en-
tire procedure of injecting uroselectan and the
subsequent roentgenographic exposures, without
obtaining anything of a diagnostic nature; that is,
for the exact condition for which one might be
using the substance. The non-secretion of the
material naturally means a kidney which at that
particular time is not functioning. In some cases,
as of reflex anuria, this may be only temporary,
while in other conditions of actual renal destruc-
tion, the exact type of pathology cannot be fore-
told, as such conditions may be present in any
of the destructive changes taking place in the kid-
ney. If the material comes through delayed and
in small amounts, only a cursory knowledge of
the pathology can be foretold, for the renal pelvis
under these conditions will probably not be well
delineated. If the material comes through in
good quantity there is probably a normal kidney
anyway; this latter knowledge at least being im-
portant many times.
Retrograde pyelography at the Post-Graduate
has been particularly of value to us from a diag-
nostic and prognostic standpoint. While we feel
that intravenous pyelography is one of the most
outstanding procedures brought out in urology
in a number of years, yet we cannot believe that
it will supplant cystoscopy nor retrograde ure-
teropyelography. This latter procedure we have
found to be positive in 96% of its usage, and
while we greet intraveneous pyelography with
open arms, we will probably still keep one hand
on the cystoscope.
The dosage and method of administration of
uroselectan has not yet been , absolutely stand-
dardized. We have usually given 30 to 40 gm.
dissolved in double distilled water in a volume
of 120 c.c. The solution is filtered thoroughly
and sterilized in a water bath or autoclave for
half an hour. The dose for children is graduated,
as in all medication. It is quite necessary that
no rubber tubing come in contact with the ma-
terial and therefore it must be given by the
syringe method. If 30 gm. are given, the entire
amount may be injected at once, while if 40 gm.
are used it is better to inject one-half of the ma-
terial and then wait for an interval of 5 minutes-
before repeating. This latter procedure probably
brings out a better resultant shadow.
Investigating this work, we followed a set
schedule: Taking the pulse, a sample of blood
from the vein and a preliminary roentgenogram.
During the injection of the material and for a few
minutes afterward, the pulse was counted con-
tinually and its variations noted. The blood was
used as a check-up against blood taken from the
vein one-half hour after the injection, and the
iodin content noted. Radiographic exposures were
made at 5 minutes, 15 minutes, 30 minutes, 1%
hours, and 3 hours. We found quite usually the
maximum intensity of radiographic result was
at the 15 minute exposure, although this would
naturally apply to normal kidneys. Not the least
value of uroselectan is the fact that it intensifies
the shadow of the kidney itself, thereby being of
remarkable value in delineating its size and posi-
tion. We were much chargrined to find it of no
value in interpreting the shadow in 3 cases of
ureteral stbne. In none did the ureter fill and
in 1 there was no shadow of the calculus at all..
These 3 were later easily checked up by the or-
dinary cystoscopic and radiographic means.
The comparative poor filling of the renal pelvis
and ureter, when considered in relation to that
of a good ureteropyelogram will be sadly felt by
the urologist.
Clinical Society North Hudson Hospital
J. Africano, M.D., Reporter
The regular monthly meeting of the Clinical
Society was held Tuesday, December 9, with Dr..
William Sweeney acting as chairman; 5 2 mem-
bers and guests present. Dr. Tannert read the
report for November: 246 admissions; 317 dis-
charges; 15 deaths, of which 10 were surgical, 4
medical, and 1 new-born; 4 autopsies were per-
formed; clinic cases 394, emergency cases 474,
ambulance calls 9 9. Several of the deaths were
briefly discussed.
The following case presentations were made
by members of the Staff:
Dr. Lawsing. Interesting Case of Duodenal Ul-
cer. J. C., male, aged 2 8, admitted complaining
of pain in the upper abdomen, gaseous eructa-
tions, slight loss of weight and headaches. In-
fluenza and tonsillectomy 7 yr. previously. Gonor-
rheal urethritis in 1921. About 6 years ago the
patient first noticed a mildly sharp pain in the
epigastrium, which would come about % hr.
after meals, last 2 hr. and be relieved by eating.
78
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
A meat meal would make the pain worse. Some
meals would not be followed by pain. He has had
3 recurrences of such attacks in the past G
years. Two years ago when he had his second
attack, radiographs were taken and he was told
he had an ulcer. He responded to treatment and
was free from pain until the present attack
which, ‘besides the pain, is accompanied by a
gnawing sensation and a fullness in the upper
abdomen. The pain comes 2 hr. after eating and
is relieved by food and sod. bicarb. Abdomen soft:
no masses; slight tenderness 2 in. above umbilicus
in the midline and extending 2 in. to the right.
Slight tenderness in both lower quadrants. X-ray.
G-I series was reported as showing a normal
pylorus and duodenum with no defects in the gas-
tric outline. The 6 hr. plate showed no gastric
retention; head of the meal was in the transverse
colon and the tail in the coils of the terminal
ileum.
The patient was put on a milk and cream diet
with alkalis and this was gradually increased; a
modified Sippy diet. He improved and was dis-
charged. In this case we have a clinical diagnosis
of duodenal ulcer which is not supported by the
gastric analyses nor by the x-ray examination.
Peptic ulcer is common; approximately 5% of all
adults dying from various causes show open or
healed peptic ulcer. Clinical history frequently
shows that ulcer has been present for many
years continuously or recurrent, but not recog-
nized. The most conclusive evidence of unhealed
peptic ulcer is derived from careful study of dis-
tress symptoms. In peptic ulcer 50% of cases
show hyperchlorhydria; 40% are within normal
limits; in less than 10% there is hypo-acidity. A
combination of burning, fullness and pronounced
hunger pain relieved by food or alkalis, occurring
periodically and rhythmically, is almost con-
clusive of duodenal ulcer.
Dr. Miller. Unusual Fibroid Tumor of the Ovary.
Mrs. A. C., aged 32, complained of a mass in
lower abdomen. Appendectomy at age 17. Nulli-
parous. Menstruation regular, non-painful, mod-
erate in amount, excepting for being scanty for
the past 3 months. She had noticed a mass in
the lower mid-abdomen, more toward the left,
and assumed she was pregnant, and this was
confirmed by a physician. When seen at my office
the patient was in excellent health, having no
complaints, desiring only prenatal care because
of the fact that she felt fetal movements. No
confirming examination was made outside of the
routine measurements, blood pressure and urin-
alysis. ■ She returned 2 months later, presenting
herself with a generalized edema, which proved
to be an anasarca. Bimanual examination reveal-
ed a globular mass in the midlower abdomen, cor-
responding to a 6 months' pregnancy. No fetal
heart heard. Blood pressure and urinalysis nor-
mal. The lower extremities were about 3 times nor-
mal size, and abdominal cavity gave evidence of
free fluid. There was no colostrum of the breasts,
nor were there any other prevailing signs of preg-
nancy. Under diet and symptomatic treatment
there was no recession of the generalized ana-
sarca. The patient was prepared for laparotomy
by removing 1500 c.c. fluid from the chest. The
abdominal cavity was filled with several liters of
straw-colored fluid, which was slowly aspirated,
and a tumor weighing 7 lb. and measuring 20
cm. in diameter, on the left ovary, was found
and removed. The patient made an uneventful
recovery.
The pathologic report was fibroma with
myxomatous degeneration. The interesting fea-
ture is the unusual generalized anasarca accom-
panying this not uncommon type of tumor.
Dr. Pearlstein considered the feature of edema:
This is supposed to be caused by a change in the
movement of water of the tissues incident to dis-
turbances of the electrolytes, as in inflammation;
or it may be due to a lesion of the “water-regu-
lator” center in the hypothalamus; or finally, it
must be explained on the basis of an endocrine
disturbance, as in cases of diabetes insipidus. In
the case presented it could not be ascribed to
congestive heart failure, the measurements of
the heart being normal, nor to portal stasis from
obstruction, nor to nephrosis; tuberculosis of the
peritoneum, and malignancy were ruled out at
the operation.
Dr. D’Acierno thought it likely that the tumor
was a coincidence along with polyserositis.
Dr. Tannert disagreed, as the patient improved
remarkably after the operation, but Dr. Schul-
man pointed out that in tuberculosis effusion due
to Concato's disease even simple exploratory lapa-
rotomy often causes marked clinical improvement.
Dr. Tataryan. Pyeltis Complicating Pregnancy.
Pyelitis is the most frequent complication of preg-
nancy. It was first mentioned in 1841, by Pierre
Rayer, with the statement that the pregnant
uterus was the cause of inflammation of the
ureters and kidney pelvis. After a silence of 50
years, Heblaut made some careful observations
on the course of pyelitis in pregnancy. In the
etiology, 2 component factors must be recognized:
urinary infection, and urinary obstruction and
stasis. Only where both obstruction and bacteri-
uria exists conjointly does an infection of the
kidney pelvis take place.
M. M., aged 17, admitted to hospital June 14.
Chief complaints were chills, fever, generalized
aches, pain in the right loin, vomiting, constipa-
tion, cough and expectoration and loss of weight,
and slight hemoptysis 1 week before. The provis-
ional diagnosis was pulmonary miliary tuber-
culosis and pregnancy. The positive findings were
a few bad teeth in the upper jaw, moist scattered
rales on both sides of the chest; fundus uteri 1
cm. below the umbilicus; fetal movements felt,
fetal heart sounds not audible. Urinalysis showed
many pus cells, clumped; smear showed B. coli.
Cystoscopic report was: trigone and post-urethra
congested, both ureteral orifices small and con-
gested. Pyelography of the right side showed
dilated ureter, distorted, and enlarged pelvis and
calyces.
On July 14, an indwelling catheter was in-
troduced and on July 19 she gave birth to a
live premature baby who expired in a few hours.
After this the patient began to improve; tempera-
ture came down to normal and she was dis-
charged as improved.
This was primarily a severe case of acute pyelitis
of pregnancy, the physical findings of the chest
misled us and prompt urologic examination and
treatment were not instituted. We believe that
introduction of indwelling ureteral catheters and
continuous drainage and irrigation of the renal
pelvis would favorably change the progress and
outcome of the case. Many cases of pyelitis of
pregnancy are recurrences of old childhood in-
fections, therefore the pediatricians should not
be satisfied with apparent cure of pyelitis in
children, but urologic examination should be
made before they are pronounced cured; for, in
pyelitis, as in syphilis, the residue is appalling.
After the patient is discharged, a follow-up
system should be instituted, as delivery does not
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
79
cure the urinary infection; postpartem pyelo-
ureterograms demonstrate that distention of the
kidney pelvis and ureters and obstructions have
been found months, even years, after delivery.
Dr. HekimJan stated that failure to diagnose
pyelitis may be due to neglect of a careful urin-
alysis or to the fact that few symptoms refer-
able to the pelvis of the kidney become manifest;
in using indwelling catheters, their size must be
gradually increased in order to give continued
drainage.
Dr. Schulman has noted that in most cases the
the pyelitis clears up after the patient gives
birth, as shown by pyelograms.
Dr. Luippold. A Case of Congestive Heart Fail-
ure with Thyrotoxicosis. Patient, a housewife,
aged 29, entered the hospital October 9 com-
plaining of extreme dyspnea, orthopnea, restless-
ness, anxiety and agitation. She was. made aware
she had a heart disorder 11 yr. ago following an
injury to the chest. No further trouble with her
heart, however, until 6 % yr. ago when she be-
came pregnant; in addition to her cardiac dis-
tress at this time, there developed a marked
edema of the lower extremities. A spontaneous
abortion occurred at 2 months and it was neces-
sary to dilate and curette, for- it was incomplete.
There ensued a period of cardiac tranquility for
2%yr., after which there was another pregnancy,
this time carried to full term. During this period
there was no edema, but her heart gave more
trouble than ever before and it was necessary to
take medicine to relieve the dyspnea. After de-
livery. which was normal except for some diffi-
culty with a retained placenta and loss of much
blood, the patient was invalided for months; in
fact she never did recover former strength.
Bight months after delivery, she had a “heart
attack” lasting a few days, which was very sim-
ilar to her present symptoms. Three months
later she once more became pregnant; this term-
inated in a miscarriage at 6 months in January,
1928. Following this the patient was weaker
than ever.
There was marked dyspnea, orthopnea, cyanosis,
extreme restlessness, gasping for air, and a tense
and anxious expression. Eyes prominent, mod-
erate exophthalmos, but the other signs of ex-
ophthalmic goiter not in evidence; pupils con-
stricted but equal, reacting normally. The neck
showed visible pulsations on either side and dis-
closed a systolic, carotid thrill and murmur on
the right side, with right jugular dilated and en-
gorged. There was no thyroid enlargement. The
chest showed a wildly tumultuous apex beat and
heart action — visible beating over the entire
chest. The tachycardia was extreme — 160-200.
No murmurs could be made out. Systolic sound
weak, diastolic accentuated and snappy. Pulse
scarcely perceptible. Lungs normal. The ab-
domen was not enlarged, but the liver was palp-
able to about 3 finger-breadths below the R. C. M.
and disclosed pulsations. There was slight edema
about the ankles and hands.
Laboratory findings: Blood count and urinalysis
showed nothing abnormal. Wassermann negative.
Icteric index 30. Van der Berg immediate direct
reaction — moderate. Basal metabolism 1-48.
Patient was given morph, sulph. and powdered
■digitalis leaf; initial dose of the digitalis was 9
gr. Within 4 hr. the pulse became more distinct
and slowed down to about 90. Next day the pa-
tient was in great distress with nausea and vomit-
ing and a choking tightness in the chest, but the
heart rate had come down to 72, and pulse was
of good quality but irregular, with premature
contractions. A systolic murmur was now easily
heard; most marked at the apex. The excellent
response to treatment was also evidenced by a
urinary output of 103 oz. during the first 24 hr.
Because of the pronounced susceptibility to digi-
talis, its dosage was cut at first to 3, then 2 gr.
per day, and this seemed to be all that was neces-
sary as a maintenance dose during the rest of
the hospitalization. The response to morphin was
also excessive, as shown by the undue somnolence.
Patient gradually rallied in strength and about
3 weeks after admission she was allowed out of
bed and limited exercise, and was content and in-
sisted upon going home.
Adopting the classification of the American
Heart Association, this case was diagnosed as:
(a) Etiologically, probably rheumatic but super-
imposed upon which there is undoubtedly a
thyrotoxicosis. There is here probably a long
standing chronic exophthalmic goiter so mild
that it is not recognizable, in which there are
acute exacerbations, induced by pregnacies and
other severe strains, (b) Anatomically: Enlarged
heart with a mitral and tricuspid insufficiency,
(c) Physiologic: Normal sinus rhythm with a sys-
tolic murmur most marked at apex, (d) Func-
tional: Class 2-B, that is, a patient having organic
heart disease, unable to carry on in less than or-
dinary activity without discomfort.
Dr. S. Africano. Diabetic Coma Complicated by
Acute Suppurative Nephritis. Mrs. L. T-, Swiss,
aged 5 2, occupation mender, admitted on Novem-
ber 25, at 11 a. m. in coma and died at 11.14 p.
m. same day. Five years ago the patient was told
she had diabetes. "Was never in coma before. She
had polyuria, polydypsia and headaches. Patient
was gradually becoming drowsy since noon of
November 24; by midnight she was unable to
answer when called and lapsed into coma; in
coma approximately 13 hr. before receiving treat-
ment. She had been given 25 units of insulin by
a physician Yz hr. before admission.
Autopsy findings: Both kidneys of average size
and on section the surfaces presented many nodu-
lar protrusions which upon stripping the capsule
were found to contain purulent material. On
section both cortices and medulla presented fre-
quent scattered areas of hemorrhages and puru-
lent exudate. The pelvis of the kidneys injected
but not enlarged. Sections showed marked de-
generative changes of both tubules and glom-
eruli with localizations of columnar cells in
abscess formation. Section of the pancreas
showed fatty infiltration and here and there
fibrosis of the islands of Langerhans.
In this case we have 2 reasons for the failure
of insulin. One is that the patient was in coma
for several hours before receiving treatment. The
other is the complication of suppurative neph-
ritis, which undoubtedly was the main factor. It
is well known that any infection in a diabetic is
a serious matter. It frequently precipitates the
coma even in mild cases, and is particularly dan-
gerous in a neglected or undiagnosed case. The
infection lowers the tolerance of a diabetic pa-
tient for glucose.
Among the serious complications which may
produce fatal coma are hypertension, arterio-
sclerosis, nephritis, gangrene, septicemia, furuncu-
losis aind tuberculosis.
Dr. Dalven. Study of 3 Cases of Nephritis.
Dr. Dalven discussed at length the various
classifications of neuphritis, their symptoms and
signs, and the laboratory findings, and reported
3 case histories.
80
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
JERSEY CITY MEDICAL CENTER
Joseph Binder, M.D., Secretary
The regular monthly meeting of the Medical
Staff of tlie Medical Center of Jersey City was held
on Thursday evening, December 11, at 8:45 p. m.,
in the Out-Patient Department. Dr. Charles B.
Kelly, presiding.
Present : Drs. O’Hanlon, Kelly, Binder, Burke,
Jaffin, Houghton, Harter, Sprague, Winter, Friele,
Hall, Schneckendorf, B. Kelly, Rundlett, De Fuccio,
White, Siegler, Fineberg, Brophy, Perkel, Faison,
Street, Cohen, Sullivan, J. Connell, Christian,
Yaehnin, Hasking, Daly, Residents and Interns.
Motion made and seconded that all rise and
stand in silent prayer for one minute in respect to
our departed colleague, Dr. J. R. Commorato.
The Commorato Memorial Committee read its
report, which was accepted and ordered be spread
in full upon the minutes. (See Obituaries)
Scientific Session
Dr. Jaffin. Abdominal Angina. Tissier, of
Lyons, France, in 1924, noted intestinal symptoms
due to peri-aortitis. These symptoms were colicky
pains, associated with diarrhea or constipation.
Others noted that this pain was increased on ex-
ertion or after eating. These symptoms very fre-
quently simulate those seen in the ■ surgical abdo-
men, and patients are therefore not infrequently
operated upon for gall-stones, with nothing being
found at operation. One must always bear in mind
that abdominal pain in the old may have a medi-
cal basis, i. e. anginal in character. The general
regimen in these cases is to instruct patients they
are to avoid any physical exertion, and not to
over-eat. To prevent or relieve anginal pain, nov-
atropin has been used, and has served to relieve
the arterial spasm during attack.
Drs. White and Macchi presented a case of
Chronic Intestinal Obstruction for further diagno-
sis. The points of interest here were dilatation of
the stomach, and visible peristalsis.
Dr. Perkel studied the radiograph of the G. I.
tract and stated that he felt that there was a
chronic partial obstruction about the duodenum,
and also a spastic rectum.
Dr. Jaffin felt that this case should receive fur-
ther medical study because this might be a func-
tional condition.
Dr. Burlce stated that this patient gave him a
definite ulcer history, and he believes that the ob-
struction is due to an organic lesion, i. e. ulcer.
The marked loss in weight, down to 93 lb., is im-
portant. This patient also presents a spinal de-
formity, and gives history of previous laparotomy
for adhesions following a cesarian section a few
years ago.
Dr. Burke and Dr. Shanik. Acute Pancreatitis.
E. W., white, male, 42, foreman, admitted August 2.
About 3 hr. before admission, patient was seized
with severe sharp colicky pain in R.V.Q., well lo-
calized, non-radiating, accompanied by nausea and
forced vomiting. Pain had persisted since onset
without any relief. Previous attacks for past 10
years, at intervals of 6 months to a year, but never
as severe or of such persistency. During the in-
terval between attacks, patient was entirely free
of pain. No G. I. disturbances, no epigastric dis-
comfort, no eructations or flatulence, bowels reg-
ular. Abdomen scaphoid, no palpable masses;
rigidity of upper right rectus muscle with marked
tenderness on superficial pressure; spasticity and
rebound tenderness present. Provisional diagnosis
was perforated peptic ulcer; cholelithiasis with
cholecystitis.
Operation disclosed a good number of stones,
black in color and varying from the size of a
grain of hemp seed to that of a cherry stone; a
stone of small cherry size impacted in the cystic
duct. The glands about the common duct were as
large as hazel nuts. The serous covering of the
gall-bladder was not much changed in appearance,
but the mucosa was greatly swollen and extremely
friable. Nine days later, both drains removed.
Dakin tube inserted, shortened 2 days later, and
finally removed in G days. Patient had unevent-
ful course and was discharged after 20 days.
Patient readmitted after 3 months. Began to be
troubled with a dull pain in the epigastrium, 4
days before admission, and had been getting pro-
gressively worse until now it felt like the “pres-
sure of a foot in the abdomen"; pain constant,
radiating to the back, not to the shoulders, asso-
ciated with vomiting; had vomited 4-5 times before
admission.
Provisional diagnosis of acute pancreatitis. At
this operation found dense adhesions between the
liver and the parietal peritoneum, fibrinous ad-
hesions between the liver, stomach and duodenum.
There was a greenish edema about bile-ducts and
duodenum, and a similar edema at the base of the
membrane over the pancreas. Adhesions between
stomach and duodenum divided by sharp dissec-
tion— adhesions about duodenum separated with
finger. Edematous tissue about head of pancreas
opened bluntly and 1 rubber tube drain placed to
lateral side of duodenum. Gastrocolic membrane
opened and edematous tissue over pancreas broken
open.
Patient relieved, feels fine; 12 days postoperative.
Slight spasticity of lower abdomen with exquisite
tenderness on slightest pressure over abdomen,
especially on lower quadrant. Tympanitic, no
demonstrable fluid.
Operation — Dr. Burke. Fibrin deposits over vis-
cera in R. L. Q. Perforation closed by 2 layers
Lembert sutures, and a curtain of omentum was
stitched over the repair for additional security be-
cause of friability of the tissues. Two rubber tube
drains inserted, one in pelvis and one in ileo-cecal
region. Patient on strict regimen. Temperature
dropped to normal the following day, and has
remained normal since. Pulse 100.
Dr. Doran gave a brief resume of 6 cases of
Acute Pancreatitis.
There were 2 females and 4 males; 3 deaths, 2
females and 1 male. Two gave gall-bladder his-
tory; 2 no gall-bladder history; 2 had gall-bladder
removed previously. In 1 case findings showed a
bloody fluid; 2 had turbid fluid free in abdomen;
3 had fluid, bile-stained, localized about the pan-
creas. There were 2 autopsies; 1 showing a large
hemorrhage in head of pancreas, and 1 necrosis of
the tail of the pancreas.
Dr. De Fuccio showed the pathologic specimen
from a child of 6 months, who died with history of
persistent cyanosis without physical signs. Path-
ology of heart showed persistent, patent foramen
ovale.
Drs. Burke and Perkel presented a case of Gas-
trojejunal Ulcer.
Male, 22 years old, chronic drinker, admitted
2 years ago with duodenal perforation after beer
drinking fest. Operation at that time was an-
terior gastro-enterostomy. Patient did well until
May 1930, when he experienced sharp sudden pain.
Admitted to ward, treated medically, and discharged
improved. Readmitted July 17 and again treated
medically. Finally, patient was admitted to sur-
gical service. Radiograph by Dr. Perkel showed
a marginal ulcer at site of original gastro-enteros-
Jan., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
81
tomy. Operation by Dr. Burke. Gastro-enteros-
tomy unhitched and closed, ulcer sutured and re-
inforced with piece of omentum. The enterostomy
portion of the tube was closed and dropped back
into abdomen. Thus far patient doing nicely.
A lively discussion ensued on this case as to the
type of original operation.
Meeting adjourned at 11.30 p. m. to collation in
hospital dining room.
MERCER COUNTY
A. Dunbar Hutchinson, M.D., Reporter
The Mercer County Medical Society held its
annual meeting in the Carteret Club on Decem-
ber 10, Dr. J. S. Vanneman presiding.
The minutes of October and November meet-
ings were read and approved, after which Mr.
Woodruff, of Rutgers University Extension Course
was granted the privilege of the floor, and an-
nounced the continuation, under previous ar-
rangements, of the Post-Graduate Lectures.
The Treasurer submitted his yearly report,
which, after being audited by the Committee, Drs.
Connelly, Yazujian and Weisler-, was certified as
correct, and the Treasurer highly commended for
his efficiency, sagacity and judicious manage-
ment of the finances of the society.
Motion was carried that on and after Decem-
ber 10, 1930, all applicants elected to member-
ship, shall be elected as associate members, and
at the expiration of 1 year they may become eli-
gible to active membership.
Drs. Applestein, Cohen, ITaney, McGuigan and
Blanton were regularly elected.
The following applications were read and will
take the usual course: Drs. Harry R. Aronis, Her-
man Cohen, Morton Reese-Cohen, Thomas V.
Murto, Joseph Ragany and Peter J. Warter.
The request of Dr. G. M. Frank for transfer to
Essex County was granted.
The following officers were elected: President,
Nathan Swern; Vice-President, Wm. L. Wilbur;
Treasurer, H. R. North; Secretary-Reporter, A. D.
Plutchinson; Board of Censors, Wm. G. Schauf-
fler; Member of Nominating Committee, James J.
McGuire; alternate, H. R. North.
Delegates: J. S. Vanneman, IT. R. North, A. D.
Hutchinson, B. D. Lavine, Nathan Swern, IT. D.
Beilis, W. E. D’Arcy ; Alternates, C. R. Sista, N-
B. Oliphant, J. M. Schildkraut.
A communication from the Executive Secretary
relative to the Merchantile Finance Corporation
of New Jersey was received and filed.
A communication from Health Officer Dr. Alton
S. Fell, with reference to Infant Mortality in the
City of Trenton, was read and following discus-
sion, the President appointed the following com-
mittee to confer with the Health Officer on this
vital subject: Drs. J. J. McGuire, H. M. Rowan,
A. W. Atkinson, Wm. J. Harman, Wm. R. Little
and L. L. Friedmann.
The President, Dr. Swern, appointed Drs. Sica,
Scammell and J. H. McCullough, Sr., to draw reso-
lutions relative to the Compensation Bureau.
Following a very thorough discussion of Senate
Bills 304 and 262, by Dr. McGuire, the Society
voted to go on record as opposed to these bills,
and that the Senator and Assembly Representa-
tives from this District be so notified.
The President appointed Drs. Scammell,
Mitchell, Wilbur, Purcell and Vanneman as a
Legislative Committee to act in conjunction with
the State Welfare Committee on Legislation.
MIDDLESEX COUNTY
William C. Wilentz, M.D., Reporter
The Annual Meeting of the Middlesex County
Medical Society was held on Wednesday night,
December 17, at Pfaff’s Restaurant, Metuchen,
with an excellent attendance.
The membership committee reported favorably
on the application of Dr. Smith, of New Bruns-
wick. On motion of Dr. McKiernan, seconded by
Dr. Spencer, this application was passed by the
society.
Dr. Johnson read the Treasurer’s Report for
the year and showed our society in very good
financial condition. He stated, however, that
there were several members who were not paid
up in their dues and warned them that they would
be dropped from the roll if the matter was not
taken care of immediately.
A motion was made and seconded that the so-
ciety pay for the expenses of this dinner and the
entertainment. The motion was passed.
The application of Drs. Toy, of Milltown, and
Fishkoff, of Perth Amboy, were read and refer-
red to the Membership Committee.
A communication was read from the Red Cross
asking the society to purchase a Health Bond
and in that way give a donation. On vote, the
society decided not to buy the bond.
A motion was passed to the effect that the Pro-
gram Committee investigate the feasibility of
holding all of the county meetings in one place,
and of having the meetings in the evening, as
well as combining social events with the meeting.
The Nominating Committee forwarded the
names of the following as officers and delegates:
President, William McCormick, Perth Amboy;
Vice-President, Robert McKiernan, New Bruns-
wick; Secretary, Samuel Berkow, Perth Amboy;
Treasurer, Frank C. Johnson, New Brunswick.
Delegates: Joseph Mark, Woodbridge; Frank C.
Johnson, New Brunswick. Nominating Delegate:
F. C. Johnson; Alternate, J. Mark.
Dr. Brown, the retiring President, gave a short
talk in which he thanked all the members for
their support during the year and also thanked
the officers for their great assistance in making
the past year a very successful one.
Dr. McCormick then occupied the chair and
asked Dr. J. V. Smith to introduce Dr. Grattan
who was the speaker of the evening.
Dr. Grattan, who is Chief Consultant Plastic
Surgeon to the Allied Hospitals in New York
City, delivered a splendid and most interesting
talk on treatment of old scars and deformities of
the nose. His talk was illustrated by lantern
slides.
The society gave Dr. Grattan a rising vote of
thanks for his most interesting talk.
Professional entertainment and a delicious sup-
per were catered to the society.
S2
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
Medical Section Rutgers Club
J. H. Rowland, M.D., Secretary
The regular monthly meeting of the Medical
Section of the Rutgers Club was held on Friday
evening, December 19, at the Elks’ Club, New
Brunswick, Dr. Klein presiding. There were 30
members, friends and guests present.
There being no business to transact, the speaker
of the evening was immediately introduced. Dr.
Harry Koster, of Brooklyn, spoke on "'Spinal An-
esthesia”. Dr. Koster emphasized contraindica-
tions for spinal anesthesia, which are: cerebellar
tumor, infection along the site of spinal injection,
and types of fractures of the skull with pressure
symptoms. He mentioned many reasons why
spinal anesthesia was of choice in any operation
and spoke of the more complete and normal re-
laxation, lessening of complications, and safety of
its use with particular relation to paralysis of the
respiratory center. Dr. Koster, who is very en-
thusiastic about the use of spinal anesthesia,
bases his opinion on experience in 7000 cases.
Spinal anesthesia was illustrated, together with
various types of operations, by moving pictures.
After the meeting the , members adjourned to
the dining room, where they were entertained by
the hosts of the evening — ‘Doctors Gruessner,
Gutmann, Haight and Haywood.
MONMOUTH COUNTY
Wiliam Von Oelisen, M.D., Reporter
The annual meeting of the Monmouth County
Medical Society was held at the Country Inn,
Freehold, December 9, with the President, Dr!
James A. Fisher, in the chair. Minutes of the
previous meeting were read and accepted with
minor corrections.
The applications of Drs. Douglas, Haines and
Levine were presented and on motion of Dr. O.
K. Parry, seconded .by Dr. W. W. Beveridge, it
was voted that these applications would have' to
take the course as laid down in the new state
by-laws; that is, that the secretary must, write to
the Biographical Department of the American
Medical Society for any material they may have
relating to the applicants.
The application 'of Dr. Millard B. Ervin, of
Matawan, for permission to join the Middlesex
County Medical Society was granted.
On motion of Dr. J. C. Clayton, seconded by Dr.
Brown, it was voted that the secretary be em-
powered to have copies printed of the “Code of
Ethics” and a fee schedule, to be sent to all
present members and to all new applicants.
The resignation of Dr. H. B. Slocum, as of June
3, 193 0, as a Delegate to the State Society was
read and on motion of Dr. W. K. Campbell, sec-
onded by Dr. Warner, it was voted to accept this
i esignation and that Dr. "W. G. Herrman be ap-
pointed in his place, the appointment to be en-
acted as of the date of Dr. Slocum's resignation.
The Nominating Committee reported as fol-
lows: President, William K. Campbell, Long-
Branch; Vice-President, Stanley Nichols, Long
Branch; Secretary, Daniel F. Featherston, As"-
bury Park; Treasurer, Robert E. Watkins, Bel-
mar; Reporter,. William Von Oehsen, Bradley
Beach; Board of Censors, John C. Clayton, Free-
hold; Samuel Hausman, Red Bank; and William
G. Herrman, Asbury Park.
Delegate to State Society for 3 years, W. G
Herrman, Asbury Park; Alternate, J. C. Clayton.
Dr W. G. Herrman was also designated as
member of the Nominating Committee from Mon-
mouth County. I
J he Secretary was instructed to cast one bal-
lot for election of the entire ticket.
Dis. Warner, Bryan and Beveridge spoke at
length on objections to the Abell Committee Re-
port and Senate Bill 304, and on motion of
Dr. James A. Fisher, seconded by Dr. W. H. Fair-
banks, the secretary was ordered to write to the
State Senator, Assemblmen and others, stating
their objections.
Dr W. K. Campbell appointed as an Educa-
tional Committee to act on the Post-Graduate
ourse of Instruction, arranged by the State
.Medical Society and Rutgers University, Altschul
1 To ut, and Featherston.
The treasurer reported for the year of 1930 as
follows:
Bank Balance from previous year .... $ 213 14
Total received in dues for 1930 1 6 3 o!oo
•total funds .... .... $1843 14
Expenditures for 1930 ! !!!! 1706 34
Balance on deposit Dec. 9, 1930 ITTmlso
A turkey dinner was served to the 35 members
present.
Marcus A. Curry, M.D., Reporter
A regular quarterly meeting of the Morris
rwl ynMe?iCal Society was held the evening ol
Decembei 18, in the recreation hall of the cafe-
teria building at the New Jersey State Hospital
at Greystone Park; the society enjoying the privil-
ege extended by the Board of Managers and Chief
Executive Officer Dr. Curry. President Sutphen
presided over a gathering of more than GO in-
< hiding members of the Summit Medical Society
also Dr. VanBuren, of New York, and various
newer members of the medical staff of the in-
stitution.
Routine business included the reading and ap-
proval ot minutes of the annual meeting in Sep-
tember, a special meeting in November, the pro-
ceedings of meetings of the executive committee-
a floial tribute to late member Noble PI. Adsit
ol Succasunna, who passed away November 22’
and the appointment of a committee on me-
morial resolutions; also conferences with the
county Board of Chosen Freeholders in reference
o the coroner situation and indicating their
willingness to cooperate with the society.
The resignation of Percy L. Smith, now prac-
hemg ip Utica, New York, was received, and the
secretary also reported Dr. Weisenhoffer, recently
resigned of Schenectady, New York, now eligible
for membership in that county society.
Dr. J Henry Harrington, of Rockaway, was
proposed for membership; this being duly re-
fened to the credentials committee.
Dr. Young reported having audited the Treas-
111 ers books and found them correct. Dr. Sher-
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jan., 1931
man, for the Committee on Public -Relations, re-
ported progress. Dr. Lathrope reported that the
Committee on Revision of Constitution and By-
Laws had completed the work, a copy of the
adopted revision being' in the hands of the mem-
bers, and suggested that the committee be now
discharged.
The event of the evening was a paper by Dr.
William Barclay Parsons, of the Presbyterian
Hospital Medical Center, New Y'ork, the topic
being “Indications for Surgery in Diseases of the
Thyroid". Dr. Parsons presented his subject in
a manner that immediately invited and held the
interest of his audience. The introductory was
that in the treatment of the various diseases of
the thyroid gland, various methods are in use;
involving doing nothing, the use of iodin, gland-
ular extract, radiotherapy, and operation; sur-
gery probably has the wider application than any
other single form of treatment, being called upon
in the infections, tumors, and some of the dis-
turbances in physiologic function. Dr. Parsons
covered in an able and detailed way, infections,
neoplasms, adenomas, and indicated surgery to
drain an abscess of the thyroid gland; to remove
localized tuberculosis; to relieve pressure from an
adenoma or Reidel’s struma; in carcinoma and
other malignancies; in adenoma without hyper-
thyroidism, to improve the appearance, to aid or
prevent pressure, and to avoid the development
of hyperthyroidism and carcinoma; also in cases
with hyperthyroidism as a method with a high
percentage of cure and a low element of risk,
particularly as a safeguard before cardiac damage
has occurred, or in the presence of cardiac dam-
age, to effect improvement in symptoms and in-
terrupt the vicious cycle.
The paper was enthusiastically received and
the discussion was extensive; those taking part
being Drs. VanBuren, Curry, Larson, Pickney,
Frost, Glazebrook, Lathrope, McMahon, Rice,
Ward, Tiedeback, Collins, Young, Rubin, Thomas,
Emory and Abell.
PASSAIC COUNTY
Wayne W. Hall, M.D., Reporter
The December meeting of the Passaic County
Medical Society was held at the Health Center,
Paterson, December 10, at 8.30 p. m., Dr. Joseph
Morrill presiding, with 70 members present. The
minutes of the November meeting were approved
as read.
The Censors’ report approved the applications
of the following doctors: S. Rosa Frank, 365 Park
Ave., Paterson, and Jacob Warren 666 Broadway,
Paterson. The following applications were re-
ceived and referred to the Board of Censors foi
investigation; Morris S. Joelson, 122 Paterson St.,
Paterson, and F. R. Palmer, 27 Monroe St.,
Passaic.
Bills S. 262 and 304, proposing to place all Boards
of Examiners under control of the State Board
of Education, was discussed. As the passing of
this law would require the turning over of all
monies to the State Treasury, the State Medical
Society should oppose it because of the loss of
funds with which to combat illegal practice. It
was moved and seconded that a letter protesting
this be sent to our legislators.
Prof. John H. Stokes, head of the Department
of Syphilology and Dermatology at the University
of Pennsylvania Medical School, and formerly
connected with the Mayo Clinic in a similai
capacity, and author of “Modern Clinical Syphil-
ology’', one of the best written authoritative texts
in the English language, spoke on “Preventing
the Transmission of Syphilis by Control of In-
fectiousness”.
Dr. H. H. Lucas, of Paterson, reported on the
establishment of a Psychiatric Clinic in the Gen-
eral Hospital.
After much interesting discussion of these
highly appreciated papers the meeting adjourned.
UNION COUNTY
Westfield Medical Society
Frederick Adrian Kinck, M.D., Reporter
The December meeting of this society was held
at the home of Dr. George S. Daird on December
9. A full representation of members was present.
As President iSalvate was ill, Vice-President
Lowell presided.
After the regular routine business, Dr. Louis G.
Newman read a very interesting paper on “Heart
Lesions”.
The discussion was very spirited as to how
much should be told the patient, whether he
could take better care of himself and cooperate
with his physician, or whether he would be so
frightened his condition would become much
worse.
Refreshments were served and the meeting ad-
journed after a vote of thanks to Dr. and Mrs.
Laird for their hospitality.
Obituaries
HEDGES, Benjamin Van Doren, of Plainfield,
died at his home November 2, 1930, after an ill-
ness of 2 weeks’ duration. Dr. Hedges was 65
years of age and had been suffering from a
cardiac affection for several years. He was born
in Trenton, the son of Joseph E. Hedges and his
wife Ann Elizabeth Van Doren. He was graduated
from Princeton University in 1888 and from the
College of Physicians and Surgeons of New York
in 1892, and began his practice here in 1894. He
was a member of the American College of Surgeons,
American Medical Association, New Jersey State
Medical Society, consulting surgeon of Muhlenberg
Hospital, Plainfield, and Bonnie Burns Sana-
torium, of Union County; former president of the
Society of Surgeons of New Jersey, the New Jersey
1 State Sanitary Association, the New Jersey State
Pediatric Society, the Plainfield Board of Health,
former member for 17 years of the Plainfield Board
of Education and former member of the Plainfield
Public Library Board.
Resolutions of the Union County Medical So-
ciety :
In the passing of Dr. Benjamin Van Doren
Hedges, the Union County Medical Society has
lost a loyal and valuable member.
For a quarter of a century he has been one
of the outstanding members of this society.
His scientific contributions were always of the
highest order and he stood for the highest ideals
in medicine.
84
Journal of the medical society of new jersey
Jan., 1931
Therefore, be it resolved: that our sincere sym-
pathy be extended to his bereaved family, and that
the society attend his obsequies.
Be it further resolved, that these resolutions be
spread upon the minutes of the society, that a
copy be sent to his family and to the press.
Signed:
Norton L. Wilson
Harry V. Hubbard
Watson B. Morris
COMMORATO, John, of Jersey City, the per-
sonal physician to Mayor Frank Hague, and a
member of the Staff of Jersey City Hospital and
of St. Francis’ Hospital, died in the last named
institution on November 30, at the age of 45
years.
Resolutions on Death of Dr. Conumorato
At a special meeting of the Director and Medi-
cal Staff of the Medical Center of Jersey City, held
December 2, 1930, the following resolutions were
unanimously adopted:
Whereas, in memory of the loss suffered by the
death of our associate, John R. Commorato, M.D.,
we recognize again the uncertainty of human af-
fairs and desiring to express our appreciation of
the faithful and able manner in which he has at-
tended the sick as Visiting Physician during the
many years he has been connected with our in-
stitution ; be it
Resolved, that in the death of Dr. John R. Com-
morato the Medical Center of Jersey City mourns
the loss of skilfull and conscientious colleague.
Desiring to convey to his family this testimony
of our regard and appreciation, it is directed that
a copy of these proceedings be sent to them and
also that they be entered in full on the records,
as a perpetual Memorial of the love and esteem
in which he was held by the Director and Medical
Staff.
Committee: Drs. Rundlett, DeFuccio
and Von der Leith.
McCORMICK, Daniel L., of 9 Tichenor Street,
Newark, was killed in an automobile accident on
the highway between Trenton and Princeton, No-
vember 27, as he was returning home from a
Thanksgiving Day family reunion.
Dr. McCormick was born in Elizabeth in 1874
the son of the late Judge Thomas F. and Elizabeth
McCormick. He was educated in Seton Hall Col-
lege, and was graduated by the College of Physi-
cians and Surgeons in New York about 35 years
ago.
He practiced medicine in Jersey City 6 years and
28 years ago came to Newark and opened an
office in Mulberry Street. Later he moved to
West Kinney Street and for the last 15 years his
home and office have been at 9 Tichenor Street.
D* • McCormick was appointed a member of the
Newark Board of Health by the late Mayor Ray-
mond when he took office January 1, 1915 and
was reappointed 2 years later. He was one of
the Mayor's .physicians and also was the physician
of The Newark Evening News for its employees
During Dr. McCormick’s service on the Board
of Health, between January 1915, and November
J917, he was chairman of the sanitary committee.
Dr. McCormick was a member of the Academy
of Medicine, Essex County Medical Society, the
Medical Society of New Jersey and the American
Medical Association.
Resolution ol’ Camden County Medical Society on
the Death of Dr. Dowling Benjamin
“Whereas: Dr. Dowling Benjamin who has
honored the Medical Profession with unswerving
allegiance to its high ideals, and with tireless ef-
forts for the afflicted under his care, as well as
with citizenship that was unselfish and thought-
ful, has been called from this earthly life; there-
loie be it Resolved that we, his fellow practition-
ers in Camden do hereby give expression of sor-
row in his passing.
1 he notable career of Dr. Benjamin is worthy
of our sincere commendation; and a few of the
High Spots or activities may be properly refer-
red to herein.
As an original member of the Cooper Hospital
staff, he is credited with the first introduction of
surgical asepsis in said institution.
In 1882 he was responsible for the rejuvenation of
the Camden City Medical Society, which fact led
to the many years of prolific charity through the
present Camden City Dispensary; as well as fur-
nished the medical profession with a permanent
hall for our meetings. He was a prominent factor
m obtaining an artesian water supply for Cam-
den which literally stamped out typhoid fever.
His personal influence with Mr. Andrew Car-
negie was responsible for the erection of the Main
Library of our city.
water, also a Lecturer in th-
Medico- Chirurgical College of Philadelphia; an.
was very conspicuous as a medical expert in ou
local Courts, as well as the Philadelphia Courts
and by local practitioners he was considered to b.
the best read man in our professional circle.
Be it further Resolved: That a copy of thes.
lesolutions shall be entered upon the minutes oi
. . society, and a copy of the same be forwarder
to the family of our deceased member.
Signed,
H. F. Palm, M.D.
A. Haines Lippincott, M.D.
Alexander MacAlister, M.D.”
MORbE, George Vane, of 70 Watsessing Avenue
Bloomfield died December 12 at the Homeopathic
Hospital, East Orange, after an illness of a month
He was 42 years old and had practiced medicine
in Bloomfield 15 years.
Dr. Morse began his practice in Bloomfield after
graduation from the University of Michigan and
the New York Homeopathic Medical College and
Hospital. He served during the World War in
the Medical Corps of the American Expeditionary
Forces in France. Upon his return he specialized
in surgery.
As a surgeon he became well known in Essex
C ounty He was a member of the Essex County
. ledical Society, the New Jersey State Medi-
cal Society an the American Medical Associa-
tion, and was a former president of the Associated
i nysicians of Montclair and vicinty.
He served on the senior surgical staff of the
Homeopathic Hospital, in the out-patient depart-
ment of the Mountainside Hospital, as consulting
obstetrician to the Community Hospital, Mont-
clair, and as an honorary member of the staff at
St. Vincent’s Hospital, Montclair.
85
Journal of The Medical Society of New J ersey
Under the Direction
of the Committee on Publication
Vol. XXVIII., No. 2 ORANGE, N. J., FEBRUARY, 1930
RECURRING POSTOPERATIVE
PAROTITIS
Harold S. Davidson, M.D.,
Associate in Medicine, Atlantic City Hospital,
Atlantic City, N. J.
Parotitis as a postoperative complication is
not unusual but its occurrence twice in the same
patient after 2 clean abdominal operations is
unusual enough to warrant a report. The pa-
tient was operated upon by cesarean section
for contracted pelvis 5 years previous to the
second operation. Immediately after the first
operation left parotitis, developed, and went on
to suppuration, necessitating incision and drain-
age. She was so extremely ill that her sur-
geon advised her not to conceive again, but 5
years later she consulted me because she had
missed a menstrual period and feared she was
pregnant. Examination confirmed her sus-
picion. Acting upon the advice of her sur-
geon, she was referred to Dr. D. B. Allman,
at the Atlantic City Hospital, who, under gas
and ether anesthesia, performed a therapeutic
abortion, removed a right cystic ovary, tied off
both fallopian tubes and removed a normal-
looking appendix. The patient reacted very
well from the operation, having but little dis-
comfort, taking liquids and being free of
fever. During the night of the second day after
operation she developed a chill, fever of 103° F.,
and pain and swelling of the left parotid gland.
Ice was applied. The gland continued to swell,
became red, and dysphagia appeared ; due to
the encroachment of the mass on the lateral wall
of the pharynx. The leukocyte count was
13,500. After 5 days, pointing appeared, and
the gland was incised but only a few drops of
serosanguineous material were expressed. Un-
fortunately, a culture was not made. She made
an uneventful recovery.
Most writers on this subject believe that the
infection occurs as either an ascending infec-
tion of Stenson’s duct, or from pyemia or em-
bolism.
Hanan and Pilliet, in 1899, first advanced
the idea of ascending ductal infection. They,
however, pointed out that inflammation around
the mouth of the duct occurred, which was not
the case in my patient, nor was pyemia a fea-
ture of this case. Paget, quoted by Lynn (Surg.
Gyn. & Obs., 34:367, 1922), believed that
secondary parotitis was sympathetic, basing his
opinion on the occurrence of changes in the gen-
erative organs during epidemic mumps. This, as
an etiologic factor, has largely been discarded,
however, since it now is known that parotitis
is not any more common a complication of
pelvic than of intraabdominal conditions. Deav-
er suggested that traumatism during anesthesia
might be a factor, but Lynn points out that
many cases in which forcible manipulation of
the jaw is necessary do not develop parotitis.
Again, this complication occurs in abdominal
operations performed under local anesthesia.
Jones reported a case occurring in a patient
with recurring appendicitis; in the first attack
the abscess was opened and drained and bila-
teral parotitis occurred ; 1 year later the abscess
was again opened and drained and again the
bilateral parotitis occurred ; the following year
there was another attack of appendicitis and
this time the abscess was drained and the ap-
pendix removed, and again there followed a
bilateral parotitis.
80
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1331
Predisposing factors are said to be chronic
oral infection and decreased resistance to in-
fection due to debilitating diseases. Neither of
these factors could be considered in my case;
oral hygiene here was excellent and there was
no debilitating condition ; in fact, she went to
each operation in excellent health.
Fecal vomiting has been advanced as a cause
(Kaiser: Munchener, Med. Wochsch., 68:
1385, 1921) whereby the bacterial flora of
the mouth would be increased. There was no
vomiting of any sort by this patient.
The high mortality of this complication
would speak for the hematogenous route of in-
fection, but in pyemic processes with secondary
abscesses in various organs the parotid gland
is rarely involved.
1 he onset is that of an acute suppurative
process. There is usually a chill, abrupt rise
of temperature to 103 F. or more and always
pain over 1 or both parotid glands. In children
there may be delirium. The leukocyte count
will reveal a polymorphonuclear leukocytosis ;
then swelling and redness appear with trismus
and dysphagia. The condition may resolve
spontaneously or fluctuation may develop and
demand incision. Humphrey and Sherwood
(Minn. Med., 11:722, 1928) point out that,
because of the very thick gland capsule, fluctua-
tion is difficult to elicit and that the surgeon
should not wait longer than 48 hours if there
is not subsidence of symptoms (Peightal Am.
J. Obs. & Gyn., 10:88, 1928). Gangrene of
the gland is a possibility.
The treatment is preventive, symptomatic or
surgical.
Collins (Surg. Gyn. & Obs., 10:404, 1919)
states that the best preventive measure is to
keep the gland actively discharging a current
of secretion down Stenson’s duct into the
mouth. After trying several methods, he
finally concluded that the best was to give the
patient an old fashioned lemon candy stick to
suck, as acids excite the parotid gland to secrete
There apparently is not enough secretion swal-
lowed to excite active peristalsis of the stomach
or bowels. This precautionary measure was
neglected in my case. Since she once before
had a complicating parotitis, such precaution
might have been a means of preventing recur-
rence of the complication.
TUBE FLAPS IN RECONSTRUCTIVE
SURGERY OF THE FACE
Lyndon A. Peer, M.D.,
Newark, N. J.
(From the Plastic Surgery Department, Newark
Bye and Ear Infirmary)
While the principles involved in making and
using pedunculated skin flaps have long been
known, it was not until the World War that
definite rules for their preparation were formu-
lated ; based upon a large amount of surgical
experience. In the first operations during the
war, trial was made of the then known meth-
ods, many of which had been based on 1 case
only, the procedures being thereafter assid-
uously copied from older books to new with-
out test of merit. The main weaknesses of
these earlier methods were lack of understand-
ing of the necessity for a lining in all mucous
lined cavities and the tendency to hurry the
operation. To Major IT D. Gillies and his
associates belongs the credit of perfecting the
tube flaps. This paper explains their prepara-
tion and use in practice at the Newark Eye and
Ear Infirmary. The photographs show each
step in the restoration of a partial loss of the
ear.
Knowledge of the anatomy and physiology
of the skin will aid in selection of .the appro-
priate graft to cover any given defect. Most
problems of reconstructive work are surgical
in character, and a knowledge of asepsis and
of the correct handling of tissues is essential.
Association with an active plastic surgery clinic
is helpful, but the basic principles which under-
lie the technical application of plastic pro-
cedures are those of general surgery.
Thiersch grafts are thin shavings of the epi-
dermis including a portion of the germinal
layer. Under proper conditions they always
grow because the epidermis is normally nourish-
ed by lymph from the coriutn, and when cut
away and placed on a denuded surface, it again,
in the absence of corium, has an abundant
lymph supply from the severed vessels of the
surface. The Thiersch graft is indicated where
a thin covering is desired which is almost sure
to “take”. Because it tends to assume a
prune-juice color, it is often used to replace
superficial loss of skin in burned areas, the
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
S 7
graft blending well with the surrounding dis-
colored skin. It is not suitable where deep
scars have been removed because scar tissue
will again form beneath the graft.
Full-thickness grafts include the epidermis
and corium, but not the subcutaneous fat.
These do not “take” as often as the Thiersch
graft because the corium is transferred to a
new surface where it must obtain nourishment
from lymph until new vessels have grown into
its substance. It may be used to repair any
skin loss of the face where there is not deep
scarring or distortion of the lips or nose. Tissue
loss from one eyelid can be replaced by a full-
thickness graft from the uninjured one.
Tube flaps may be formed on any surface
where the skin is loose. They consist of a tube
of skin containing its subcutaneous fat layer.
The skin is connected at either end with the ad-
jacent skin surface, much as the handle is con-
nected with the suit case, and the handle, or
tube, receives nourishment through each of
these attachments. The end which is later to
be severed and attached in a new area is
called the distal end, and the connection which
is left in place to furnish nourishment until the
distal portion can support itself, is called the
central end. The procedure whereby one end is
incompletely divided, and later completely de-
tached, is called delaying the tube flap. This
is always advisable as it causes the other at-
tachment to play a larger part in the tube’s
circulation and prepares it for the more radical
change when the incompletely divided end is
severed.
Tube flaps are necessary in the repair of
deep scars involving distortion of the lips, nose
and ears ; and for actual loss of the lips, nose
or ears. Complete loss of the nose is best con-
structed from a forehead flap.
One should exercise great care in matching
the color, hair-bearing character, and texture
of the graft with the skin in the area of defect.
A white patch of skin from an arm would ap-
pear grotesque on the face of a dark skinned
individual; in such a case a tube flap from the
neck, migrated up into position, would be pre-
ferable.
Upon these facts the surgeon studies each
case, and if the condition is extensive, as with
burns of the face, he wisely utilizes a variety
of skin grafts. Generally speaking, the sim-
plest method of repair is the best, since one
may later use a more extensive procedure in
case the first fails. Narrow scars not causing
distortion are excised and the skin edges
brought together. A depression is filled in
with fat or muscle rotated in from the sides,
with a portion of their blood and nerve supplies
attached ; or, where these are not available, a
fat transplant from the leg is used. A muscle
flap which has lost its nerve supply will atrophy.
Cartilage also may be used to fill in defects;
clinical evidence of its permanence when buried
beneath the skin has been shown experiment-
ally by Davis. Flat, thin, burn scars may be
replaced by a Thiersch graft and the ectropion
corrected by means of a full-thickness graft
from the uninjured eyelid. A distortion of
the lips and nose or partial loss of an ear must,
however, be corrected by a tube flap, taken from
the neck, if it is not badly burned, or from a
distant part, such as the arm.
Technic for Making Tube Flap
Preparation. After a suitable location has
been determined, keeping in mind the matching
of the tube skin with the skin in the area of
defect, and the absence of hair where hair is
not desired, the surface is scrubbed well with
tincture of green soap, washed with alcohol, and
then with a mixture of alcohol and ether.
Strong antiseptics are contraindicated.
Anesthesia. Local anesthesia is used except-
ing with children; we prefer 1% novocain with
<S drops of adrenalin to the ounce. General in-
filtration is better than nerve block because of
the small amount of bleeding with the latter
method.
Operation. Two parallel incisions are made,
not less than 1 in. apart and about 3 in. long.
In general, the length of the tube should not
be more than 3 times its width, thus insuring
a good blood supply. The skin with subcutan-
eous fat is dissected from the deep fascia be-
tween the parallel incisions, taking enough sub-
cutaneous tissue to provide adequate blood for
the skin, but not enough to render formation of
a tube difficult. The skin edges are then brought
together below with silk sutures, forming a
skin tube entirely free except for a connection
at either end. The free skin margins from
which the tube was raised are then undermined
and sutured, effecting a complete closure with
88
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
no raw surfaces exposed. If the defect can-
not be closed, a Thiersch graft is applied to
the uncovered area.
Stitches are removed after 5 days and the
tube is not disturbed for 2 weeks. It is then
safer to partly sever the distal end and re-
suture it in place. This throws the burden of
blood supply on the central end and prepares
it for the period when the distal extremity is
completely detached, 1 week later. At this time
all scar tissue is removed about the area which
is to receive the graft, and the bleeding is con-
trolled by pressure or cat-gut ligatures. The
tube is opened out flat for not more than 1/3
its length, and sutured in its new position.
Moderate pressure should be applied to secure
firm apposition; but if the tube turns blue it
should be returned at once to its original site.
A slight blueness about the margins may be
disregarded but firm pressure should be ap-
plied in such case. Scarification of the flap,
to allow surface drainage until proper vessel
drainage is established, may be used to relieve
venous congestion.
If a mucous surface is to be repaired (as
with loss of the lip) it is necessary to have a
flap which is covered with epithelium on both
sides, and this may be accomplished by cover-
ing the under surface of the graft with a
Thiersch graft before transferring, or by
folding the opened end of the tube and ap-
proximating the raw surfaces.
The central end of the flap is delayed when
the distal end has been attached in its new
location for a week, and after another week
has elapsed it is completely severed and
sutured to cover the remainder of the area of
defect. Sutures are removed in 5 days and
the graft is kept covered with vaseline for 3
weeks.
Precautions
(1) If a tube is used from the arm great
care is necessary to maintain the arm in a
comfortable relaxed position, and at the same
time to insure against tension on the attach-
ment. Measurements should always be made
before the operation to be sure that the tube
is so placed that it will cover the desired area
of the face when the arm is swung up with-
out tension on the pedicle.
(2) Nervous individuals do not tolerate
the arm posture, and it is best to take the
tube from a neighboring area.
(3) The method of delaying transfer of
one end of the tube flap, by first partially sev-
ering its blood supply, is always recommend-
ed. The slowest way is the surest way in re-
constructive surgery.
(4) If the end of the tube becomes pale
when it is cut free, it indicates that there is
excellent venous drainage, but very little
blood coming into the tube. This is not usually
serious, and may be relieved by application of
warm compresses.
(5) A venous congestion, as indicated by
a blue color, endangers life of the flap, and
where this extends beyond the margins, the
flap should be replaced and pressure applied
to the blue area. Scarification may also be
employed.
(6) Avoid cutting and shaping the graft
when it is first sutured in its new position.
This can always be done later when a firm
attachment has been obtained.
(7) Avoid pointed flaps, as they are apt
to develop necrosis from insufficient blood
supply.
(8) A careful choice of skin should be
made as to texture, color and thickness.
(9) Avoid transplanting hair-bearing skin
to non-hair-bearing areas. It is always wise
to mark out the extent of flap before the skin
surface is shaved. X-ray treatment for the
removal of hair is not satisfactory because
the dosage necessary to remove hair also
causes changes in the skin.
(10) All crusts should be -removed from
the suture line at least once a day, by means
of cotton applicators dipped in hydrogen per-
oxide, and sterile vaseline applied. Where
crusts exist the skin edges tend to dip down
and form small pits which are unsightly.
When vaseline is applied to a clean wound
the serum oozes up through the grease cover-
ing and does not form crusts which stick to
the skin.
(11") A freshly made tube flap may develop
gangrene of its central and most dependent
portion. This usually occurs on the first night
following operation and is due to the patient
lying on the flap, or to a tight bandage. Great
care should be used in protecting the tube from
pressure.
Feb.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
89 •
(1) Partial loss of an ear, with a tube flap formed
from the loose skin behind the ear. Pictures
are taken with sutures in place to more
clearly indicate the procedures. A. rep-
resents the distal end. B. rep-
resents the central end.
(2) The tube has been delayed by partly cutting the
distal end at A, throwing the burden of blood
supply upon the central connection.
(3) The distal end has been completely severed and
sutured to the ear at A. At a later date the
tube was delayed by partly cutting the
central end at B.
(4) Tube has been completely severed. A represents
the central end sutured in place (now healed).
B represents remainder of the tube, which
is open and sutured to the surrounding
skin margins.
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
* 90
THE GASTRO INTESTINAL PATIENT*
Joseph M. Marcus, M.D.,
Senior Clinical Assistant in Gastro-Enterology,
Mount Sinai Hospital,
New York City
1 have been called upon to deliver a talk this
evening on a seemingly dry subject — “The
Routine Examination of the Gastro-Intestinal
Patient”. This subject should, however, be
of unusual interest to every medical man be-
cause of the frequency with which gastroin-
testinal symptoms occur in many systemic dis-
orders. Very frequently a lesion of the gastro-
intestinal tract is over-looked that could have
been easily found if the patient had been put
through the ordinary routine gastric examina-
tion, and I shall give you the typical routine
that we follow at our hospital.
We naturally commence with the history, and
we attempt to pin the patient down to his chief
complaint. Exact location of the pain or dis-
tress is of utmost importance; the relationship
of this pain or distress to meals or defecation
is also very important, and may give the cue
to diagnosis. (In practically all cases of duo-
denal ulcer pain occurs from 2 to 4 hr. after
eating, while in gastric ulcer the pain is imme-
diate.)
Past history is important. Previous opera-
tions may have a bearing on the condition. Dis-
eases such as typhoid fever or dysentery may
have permanently affected the gastro-intestinal
tract. It is important to know whether there
has been aggravation or emotional upset which
may have started a gastric neurosis. A family
history of neurosis, peptic ulcer or arterio-
sclerosis may also have a bearing on the con-
dition.
Physical examination should be complete.
Palpation of the abdomen for masses, tender-
ness or rigidity should be carefully done.
The reflexes must be noted and it is important
to ascertain whether the patient is hypersensi-
tive or hyposensitive to pain ; it has been found
that often patients who are hyposensitive will
have a painless peptic ulcer unrecognized until
*(Reatl in part before the Bergen County Medi-
cal Society at Hackensack, New Jersey, September
9, 1930.)
a hemorrhage or perforation occurs. Rectal
examination should be done in every case to
rule out hemorrhoids, tight rectal sphincter,
carcinoma of the rectum, rectal shelf, etc.
Laboratory examinations are important, and
a blood Wassermann and urinalysis (chemical ,
and miscroscopic) should always be made. The
stool should be examined for blood, ova and
parasites. Gastric aspiration should be done ir.
every case unless it is contraindicated by a
cardiac condition. The Ezvald test-meal is ex-
tremely important, because presence or absence
of free hydrochloric acid may change the whole
diagnosis ; the patient may have all the signs
and symptoms of a peptic ulcer, but when free
hydrochloric acid is found to be consistently
absent we must look for another diagnosis. We
must differentiate between the true and false
achylias by the fractional test-meal. This rou-
tine when accompanied by the administration '
of neutral red and histamin gives the final ver-
dict in these cases. (The finding of a per-
sistent achylia is of utmost importance in the
diagnosis of pernicious anemia, achylia gas-
trica and functional achylia.)
In the neutral red test the procedure is the
injection of 40 mgm. of neutral red dye in-
tramuscularly and subsequent recovery of that
dye from the gastric contents. Where no free
hydrochloric acid is secreted by the stomach
no neutral red is obtained.
The Palmer test is a test for peptic ulcer
wherein we give the patient a certain amount of
0.5% hydrochloric acid, carefully and in 2
portions and where ulcer is present there will
occur typical ulcer pain which can be relieved
by an alkali.
The Rehfuss atropin test is used on pa-
tients who have had subtotal-gastrectomy; 1/40
gr. atropin sulphate is injected hypodermically
and when the mouth becomes dry, a cup of
oatmeal gruel is given and then aspirations are
made every 15 minutes. This test is to ascer-
tain the secreting power of the stomach after
such an operation.
The Vagus or psychic test-meal is given in
cases where we feel that free hydrochloric acid
is present but where we cannot obtain proof
through the usual procedure. The ordinary
fractional bucket is passed and the patient is
given an orange to chew. He expectorates both
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
91
pulp and juice. Then aspirations are carried
on every 15 minutes. This procedure will stim-
ulate psychically gastric secretion, where the
gastric nerves have not been cut.
Biliary drainage by Lyon’s method is being
supplanted by Graham’s cholecystography.
Blood studies are important in the gastroin-
testinal case to ascertain whether there is pres-
ent a cholesterinemia, bilirubinemia, eosino-
philia, etc. Ferment chemistry should be men-
tioned as it is important to determine enzy-
matic function in certain cases.
The esophagoscopic, proctoscopic, and sig-
moidoscopic examinations are important for
finding erosions, ulcerations, polyps, diverticuli,
spasms and new growths. Internal hemor-
rhoids and strictures are also located by this
method.
Fluoroscopy done with aid of the barium
meal or enema will sometimes give immediately
a diagnosis of a condition that has been over-
looked for years. I can cite the case of an
habitual drinker who was supposed to have
had an alcoholic gastritis and who could keen
nothing on his stomach. Naturally the family
physician thought this vomiting was caused by
irritation and inflammation of the stomach and
hesitated putting his patient to the expense of
special examinations. However, the patient
finally came to fluoroscopy and the diagnosis
was made in exactly 1 minute after ingestion
of the barium drink, for there was a complete,
irregular, malignant obstruction of the eso-
phagus at the cardia.
Roentgenography in a great many cases must
supplant the fluoroscopic examination, for al-
though gross defects may be seen through the
screen, careful studies of details can only be
made by means of the permanent film.
Treatment may also be regarded as diag-
nostic because very often the response to a
special diet checks up on diagnosis. The im-
portant thing in treatment of the non-surgical
gastro-intestinal patient is regulation of diet
and habits. Important medications are alkalies,
hydrochloric acid, belladonna and the sedatives
such as bromides and phenobarbital. Rest, both
physical and mental, must be considered. Oc-
casionally there is a great relief by gastric,
duodenal or colonic lavage.
While on the subject of treatment, I feel that
we cannot overlook the greatly increasing num-
ber of functional cases that are usually termed
“dyspeptic”. These patients compose 90% of
all we see with gastro-intestinal complaints, and
the conditon usually results from improper
habits of eating and living.
I think it would be proper at this time to
read an excerpt from a radio talk given by
myself for the New York Department of
Health on that type of case — -the group that
makes up 9 out of 10 patients who consult the
physician for gastro-intestinal symptoms.
The average American inhabitant of the
larger cities is the greatest offender in regard
to improper eating habits. He takes from
to 1 hour for the noon-day meal ; while the
continental European takes from 1 to 2 hours.
In our business districts there is an excited
rush for the restaurant at the short lunch
hour ; a mad hustle and bustle, the dishes
clatter, men are gulping food, some eating
from counters, some even are standing; no at-
tention is paid to the quality or the cooking of
the food. Around the corner we see men try-
ing to conduct business during the lunch hour.
Women are combining shopping and lunch. All
this is extremely- hard on the stomach and on
the individual.
It is essential to have a well balanced diet
containing nourishing and wholesome food.
Nourishment is essential for maintaining the
body weight, for growth and for supplying
energy. A diet should contain plenty of vege-
tables, both green and cooked, because they are
the most valuable foods. They contain plenty
of mineral salts and vitamins. There are many
kinds to choose from. Fruits should also be
eaten plentifully, for dried, cooked or raw
fruits are good. Milk and eggs rank next in
importance and can be tolerated by the most
■sensitive stomach. Meat is an excellent food
but too much should not be taken, as then there
would be a strain on the kidneys and the sys-
tem would store up too much harmful acid;
meat should be taken but once a day. Fats are
fuel or heat-producing foods and are present
in cream, butter and vegetable oils ; they should
be taken in moderation. Dark coarse breads,
such as rye and whole wheat, are better than
the refined white bread because they contain
roughage, thereby giving bulk to the stool ; they
92
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
also contain more minerals and vitamins. Water
is absolutely essential and at least 6 glasses
should be taken per day by the average adult ; it
should be taken upon arising and between meals
rather than with the meals.
When a person is young his stomach can
stand a great deal of abuse. As he gets older,
he must be more careful of what he puts into
his stomach. The average individual should
avoid, especially an excess of, tea, coffee and
alcoholic beverages. He should avoid peppery,
spicy and salty foods ; improperly cooked foods,
and here I may especially mention fried foods;
and should refrain from eating food too hot
or too cold. Irritating articles of diet inflame
the delicate lining of the stomach and may lead
to ulceration, and the kidneys are often affected
by such irritating substances.
As to when one should eat, a good rule to
follow is “Keep a regular meal time”. The
stomach naturally rebels when it is starved
during the day and over-burdened at night, es-
pecially with a full course dinner. Frequent
small meals are preferable always to infrequent
large ones. Don’t skip meals ; this causes ab-
normal hunger which leads to rapid eating or
over-eating and the result is indigestion. Over-
eating causes a strain not only on the stomach
but also on the heart, liver and other internal
organs.
As to how one should eat, do not follow the
example of the common type of worker or
business man in the large city who arises,
hurriedly dresses, rushes through a scanty
breakfast and hustles out to catch his train,
car or bus ; rushes through the day, probably
snatching a few mouthfuls of food at lunch
hour ; comes home at night, tired and hungry,
sits down to a large dinner and eats so much
that he over-taxes his stomach. That man is
a prospective customer for the physician. While
he is young and his organs resistant, he gets
away with it. But sooner or later normal work-
ing of the stomach and intestines becomes so
disarranged that indigestion, dyspepsia or
something worse results.
Among the rules for proper eating, “Keep
a healthy mouth” comes first. Poor teeth give
poor mastication. Infective material from de-
cayed teeth, diseased tonsils and sinuses, con-
taminates food. One must chew carefully and
eat slowly in order to grind up the food and
mix it thoroughly with the saliva which starts
the digestive process. Avoid eating when tired,
aggravated or excited, because the stomach
juices are held hack at such times and poor
digestion results. Restrict use of fluids with
meals because they tend to wash down food
without proper mastication and proper mixture
with saliva. An excess of fluids dilutes the
stomach juices, thereby inhibiting digestion,
and distention of the stomach may arise from
such an excess. Drink plenty of water upon
arising and between meals, because the body
tissues and the intestinal canal need fluid to
aid the normal disposal of waste matter.
To maintain proper digestion, one must keep
away from the “cathartic habit”, which may
cause the intestines to lose their normal func-
tion and lead to chronic constipation. It is
also important to avoid certain fads in diet
that are in vogue from time to time. They
usually do more harm than good.
In susceptible individuals use of tobacco in-
terferes with the normal digestive process. One
must not forget general hygiene, and nothing
aids normal appetite and digestion more than
recreation, fresh air, sunshine, proper exercises
and rest.
In closing, I wish to emphasize the fact that
attention given to diet and proper eating habits
is more than worth while, when we consider
that adherence to these habits may go far in
preventing disease.
FUNGUS INFECTIONS OF THE SKIN
S. J. Fanburg, M.D.,
Newark, N. J.
The subject of fungus infection of the skin
is constantly assuming greater importance in
medicine. Since the World War, particularly,
fungus diseases have gained increasing prom-
inence. Various observers have estimated that
between 50 and 85% of all people in this coun-
try have some form of fungus infection of
more or less severity. Excluding infection of
the scalp, the condition is almost twice as com-
mon in men as in women ; more common in
adults than in children. It is very prevalent
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
33
between the ages of 20 and 40. Occupation
seems to make little difference. The better
class of patients is seemingly more often af-
fected. The general practitioner frequently
sees this condition and classifies it with the
eczemas. Frequently, fungus infections are
not recognized as being parasitic and con-
tagious, a potential source of contamination to
others, very difficult to cure, often extremely
uncomfortable and many times causing eco-
nomic loss and disability.
Since 1910 when Sabouraud published a
summary of tinea cruris and associated lesions,
it has been recognized that various forms of
dermatoses, from head to foot, may be caused
bv fungi. The lesions may be extremely
varied, superficial or deep, dry or moist, scaly
or crusted, local or generalized.
It is my intention to discuss in this paper,
more or less briefly, the following forms of
diseases of the skin and scalp due to fungus in-
fection ; tinea capitis, favus, tinea barbae, tinea
circinata, pityriasis versicolor, tinea cruris, der-
matophytosis and dermatophytes.
Ringworm of the scalp is preeminently a dis-
ease of childhood and is extremely contagious,
but disappears spontaneously at the age of
puberty. It is commonly seen among poorer
classes of children in large cities and frequently
occurs in epidemics in schools and juvenile in-
stitutions. Contagion takes place directly from
child to child, or indirectly through the media
of hats, combs, brushes and towels. The com-
monest type in this country is the large patchy
form, and the earliest stage of the disease is
the minute red scaly patch. Development is
rapid and the characteristic picture soon pre-
sents itself in one or more patches of circular
discs, chiefly on the parietal regions or vertex
of the scalp. The affected hairs become dry,
brittle, and lusterless, and break off easily a
few millimeters from the surface, leaving the
characteristic stumps. The brittleness of the
hairs is due to presence of the fungi in and
around them. If untreated the disease may
persist for years, but usually disappears at
puberty leaving no scars or baldness unless
treated improperly. Occasionally tinea capitis
is accompanied by a severe inflammatory re-
action forming the so-called kerion ; an elevat-
ed, sharply defined swelling, honeycombed with
numerous follicular openings from which pur-
ulent material oozes. Pain and tenderness are
usually present, with occasional constitutional
symptoms.
Tinea capitis is to be differentiated from
seborrheic dermatitis, favus, eczema, psoriasis
and, rarely, alopecia areata. In doubtful cases
microscopic examination of the affected hairs
will settle the diagnosis. The fungi are easily
found in the short broken stumps.
In the treatment of scalp ringworm chief
reliance must be placed on x-ray epilation or
epilation with thallium acetate. Mechanical
epilation is not satisfactory ; the hairs are
brittle and easily broken and when an attempt
is made to remove them a portion usually re-
mains in the follicle and perpetuates the dis-
ease. Antiparasitic applications have been used
but are also unsatisfactory because they do not
penetrate far enough into the hair follicle. The
principle of treatment consists in removing the
hair, for with the hair go the fungi. X-ray
epilation in expert hands is quite safe. The
hair usually falls out within 2 or 3 weeks and
the scalp remains bald 4 to 6 weeks. One week
after the treatment an antiparasitic salve, such
as 5% ammoniated mercury ointment, should
be applied daily. Its object is to prevent re-in-
fection and prevent other children from con-
tamination.
Lately, thallium acetate has been used to ef-
fect epilation. It is useful in children too
young or unruly to be subjected to x-rays. The
drug is given at one dose by mouth ; 8 mgm.
per kilo of body weight. Contraindications to
use of this drug are the approach of
puberty, disproportion between age and weight,
and any disease of the kidney. The hairs be-
come loosened in a week and epilation is com-
plete in about 3 weeks. Occasionally, toxic
symptoms, such as pain in the muscles and
joints, and gastro-intestinal disturbances oc-
cur. The drug exerts its effect by acting in
some way on the sympathetic nervous system.
Favus is a disease of the scalp and of the
glabrous skin which is quite rare in this coun-
try. When seen it is usually in immigrants.
The earliest manifestations are raised ery-
thematous macules and pustules. Crusts de-
velop on these and form characteristic cups or
scutula; crusted, pea-sized yellowish discs
94
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
pierced by hairs, which are almost pure cul-
tures of the fungi. Patches, irregular in size,
and shape and more or less devoid of hair are
present. In the active stage of the disease
the affected scalp is bright red in color. The
hairs are lusterless and dry but not as brittle
as in tinea capitis. Later in the course of the
disease scarring and permanent baldness take
place. I he diagnosis depends on presence of
the scutulas, scarring, and microscopic examin-
ation. Treatment is the same as in ordinary
ringworm of the scalp.
Ringworm also affects the bearded area, par-
ticularly in men whose occupation necessitates
contact with horses and cattle. Contagion oc-
curs rarely from man to man, but frequently
from animal to man; the latter type producing
the severest infection. The disease manifests
itself either in an acute or chronic form. The
acute type resembles kerion of the scalp in
children, with its fairly well defined area of
boggy swelling, nodules, pustules and loosened
hair ; it appears in the chronic form as scaly,
slightly inflammatory patches, or as discrete
inflammatory nodules. The lesions appear us-
ually in patches although the entire bearded
area may be affected. The upper lip is almost
never involved; very few cases have been re-
ported. Differential diagnosis must be made
from eczema, seborrheic dermatitis, syphilis,
and sycosis vulgaris. In eczema and seborrhea,
the process is superficial and the hair shafts
are never involved. Syphilis causes scarring
and pigmentation. In sycosis vulgaris the
lesions are superficial papules or pustules
pierced by hairs, but hairs are not so loose, and
the upper lip is frequently affected. Micro-
scopic examination is often necessary to make
the diagnosis. In the treatment of these con-
ditions of the beard, depending on the severity
and type of the infection, reliance is to be
placed on local antiparasitic applications, me-
chanical epilation, x-ray therapy, and intra-
venous injections of iodin, such as diluted
Lugol’s solution.
Pityriasis versicolor is due to growth of the
fungus known as Microsporon furfur in the
superficial layers of the skin. It occurs most
commonly on the trunk, but may appear also
on the limbs, and rarely on the face. The
lesions consist of superficial yellowish-brown,
Feb.. 1931 I
discrete or confluent scaly patches. Slight itch-
ing may be present. The diagnosis is easily
made by scraping some of the scales and ex- 1
amining under the microscope, where the fun- 1
gus is quickly found. Treatment consists in
removing and destroying the fungi by daily
scrubbing the parts with soap and water and
then applying a saturated solution of sodium
thiosulphate. Treatment should be carried out
for at least 2 weeks after all signs of the disease
have disappeared, for reinfection is frequent.
Tinea circinata is the ordinary form of ring-1
worm of the body, and is frequently seen in
children. The infection is occasionally spread
through the medium of household pets such
as dogs and cats. The typical lesion is circular
in form, has a scaly center and an erythema- 1
tons, vesicular border. There may lie one or
many lesions. Slight itching is usually present.
Satisfactory treatment consists in the daily up- !
plication of mild ammoniated mercury oint-B
ment.
The eruption termed eczema marginatum
by Hebra, in 1869, was soon recognized as
being caused by fungi. From its site of pre-1
dilection this eruption is commonly known as
jock-strap itch. Both thighs are usually in-1
fected. The skin presents a pinkish red ap-
pearance, scaling is slight and the borders of
the eruption are sharply defined. Tiny vesicles !
may be seen along the advancing border. The
lesions may extend to involve the perineum,
the anal region, the genitals and the pubis. In
extensive cases the eruption may reach to the
thighs. Other parts of the body may be in-l
volved, such as the axilla and under the breasts.
In the latter location, maceration and ulcera- *
tion may be superadded ; owing to the presence
of heat and moisture. Treatment consists in
the application of mild antiparasitics, such as
resorcin, salicylic acid or ammoniated mercury
in salves or lotions. X-rays are a useful ad-
juvant in obstinate cases.
Forms of fungus infection which are at-
tracting much attention are the vesicular and
scaly eruptions of the hands and feet which
have received the names of dermatophytosis or
athlete’s foot. An individual susceptible to fun-
gus infection may pick up the parasite by walk-
ing barefoot on floors of gymnasiums or locker
rooms, by using contaminated golf clubs, bv
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
95
wearing infected jock-straps or leather gloves
— to mention only a few of the numerous pos-
sible ways. Given a susceptible host plus the
conditions of moisture and heat, the fungus
will thrive and produce its various manifesta-
tions.
By far the most common manifestation of
dermatophytosis is the vesicular eruption of
hands and feet. The vesicles are usually deep-
seated, discrete, fairly uniform in size, skin-
colored, and prefer the lateral aspects of the
fingers and toes. The vesicles break on ac-
count of the thinness of the skin, pressure,
heat and moisture. Between the toes macera-
tion of the skin takes place. These processes
are characterized by periods of subsidence and
outbreak and are more prevalent in the warmer
months of the year. Subjective symptoms are
usually those of marked itching and burning.
Another common form of dermatophytosis
is the scaling type which usually affects the
palms and soles and the webs of the fingers
and toes. The fourth interspace of the toes
is the favorite seat of this type. Itching is not
frequent.
On the hands and feet one occasionally sees
painful fissures of varying size and depth,
which may or may not be associated with other
forms of dermatophytosis. These cracks or
fissures may sometimes be so numerous and
painful as to incapacitate the patient. This
form of fungus infection is usually associated
with hyperkeratosis or callous formation, most
frequently seen on the ball and heel of the
foot. On the heel the appearance is that of a
horseshoe shaped, dirty-white, or yellowish
hyperkeratotic patch streaked with fissures. On
the ball of the foot split-pea-sized keratotic
patches may form and become the seat of pain-
ful, warty growths.
Mention must here be made of the lesions
described recently as epiderm.ophytes or der-
matophytes. These lesions pave the way for
an analogy between fungus infections of the
skin and syphilitic and tuberculous infections.
For example, a focus of fungus infection on
the feet may rise to a lymphangitis, or a
lymphadenitis, may permit fungi or their toxic
products to enter the blood stream to produce
chills and fever and cutaneous lesions resemb-
ling scarlet fever, erythema nodosum, dissem-
inated follicular trichophytes, etc. Many cases
of dysidrosiform and eczema-like lesions of
the hands have proved to be dermatophytes
arising from foci of infection on the feet.
These discoveries have opened up a new field
in dermatologic research.
The vesicular and squamous eruptions of the
hands and feet due to fungi, clinically and his-
tologically, resemble the symptom-complex
known as eczema. Peck maintains, in his ex-
cellent article on epidermophytosis and epi-
dermophytes, in the Archives of Dermatology
and Syphilology of July 1930, that the dysid-
rotic and squamous epidermophytes represent
an etiologically and pathogenically explained
special group of eczema, differing from an
endogenous allergic eczema, such as that caused
by foods or drugs, only through the special
constitution and origin of the allergen. These
findings are important in treatment. Many
patients who have been treated unsuccessfully
for eczema, have cleared up only when the
primary focus of mycotic infection, however
insignificant in appearance, has been eradicated.
In the treatment of dermatophytosis of the
hands and feet, the acute eruptions should be
treated as acute eczemas, with soothing lotions
or wet dressings, such as diluted Burrow’s
solution, continued for 24 to 48 hours, after
which antiparasitic remedies should be applied.
Production of a mild inflammatory reaction
aids in eradicating the infection. X-rays have
been found useful in shortening the course, by
some way changing the nutritional substratum
of the affected parts. Each case must be
treated individually. A remedy which has
given results in one case may be found abso-
lutely useless in another which appears simi-
lar.
As a correct diagnosis, of fungus disease, of
the skin is often dependent upon finding the
causative agents, which fortunately in this
group of diseases are known, a knowledge of
the means of their detection is essential. The
simplest technic for examining hair or scales,
or the tops of vesicles, is to take some of the
suspected material, place it on a clean glass
slide, add 1 or 2 drops of 30% KOH solution,
apply a cover glass and then examine under
the microscope. In the case of infected hairs
the fungi may be seen in the form of minute
96
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
closely set dots in or around the hairs, or both,
depending upon the causative organism. When
present they are very easily seen. In infections
of the hands and feet, however, search for the
organisms must be prolonged and several slides
must he examined because the fungi are more
difficult to find, and are rarely found in lesions
of the hands. When direct microscopic examin-
ations are negative, cultures may sometimes be
positive.
fhe most recent advance in diagnostic
method has been in the use of trichophytin. In
many cases of dysidrotic and squamous lesions
of the hands, when microscopic and cultural
examinations were negative, trichophytin tests
have given positive results. The trichophytin
is injected intracutaneously and the local re-
action read in 24 hours to 5 days. Delayed re-
actions are frequent. When positive, a raised
erythematous area develops at the site of in-
jection and there is a flare up in the suspected
lesions. The trichophytin test has proved that
fungi are capable of developing the allergic
state in susceptible individuals.
TREATMENT OF WHOOPING-COUGH
BY INTRAMUSCULAR INJECTIONS
OF ETHER
A. S. Finkelstein, M.D.,
Newark, N. J.
Treatment of whooping-cough still presents
numerous advocates and enthusiasts of various
methods of therapy. Laurence W. Smith, in
a review of the literature, grouped the forms
of therapy into 5 main groups: (1) A varied
assortment of drugs used systemically ; (2)
local application of drugs to the nasopharynx
and larynx; (3) vaccines in small or large
doses; (4) numerous forms of applied physio-
therapy including the use of diathermy, ultra-
violet light and the Roentgen ray; (5) the use
of ether by intramuscular injection. Experience
with the last of the above named methods
warrants our endorsement of it as the method
of choice in treatment of whooping-cough.
* (Read at the 164th Annual Meeting of the
Medical Society of New Jersey, Section on Pedia-
trics. Atlantic City, June 12, 1930.)
The literature on ether therapy in pertussis
presents a wealth of articles, mostly by foreign
authors. In 1914, Audrain first suggested use
of ether in the treatment of whooping-cough
and from 1914 until 1920, although his work
was interrupted by the War, he continued to
publish favorable reports on such ether injec-
tions. Vaccarezza and Inda, in 1921, using the
method advocated by Audrain, administered
ether intramuscularly to children ever)- other
day for 5 or 6 injections in doses of 0.5 to
2 c.c. and reported that by the third injection
the pertussis symptoms had often disappeared
entirely, the effect of the first few injections
being always more pronounced than the effect
of the later ones. They emphasized the ab-
sence of any ill effects, in answer to Auricchio
who, in a report on 24 cases, brought out the
fact that ether exerted a deleterious effect by
bringing about a state of excitement in children
with the spasmophilic diathesis.
I he European journals of 1921-22 contained
many reports favoring the use of ether as a
specific for whooping-cough. Martinez. Ver-
onese, D’Aroma, Lassabliere, Klotz, and Vel-
toni are but a few of the many who reported
favorable results in small series of cases; all
stating that ether gave more satisfactory results
than any other drugs. D’Aroma gave in several
cases as high as 6 c.c. of ether daily. Genoese
reported on 50 patients benefited In- this treat-
ment and believed ether superior to vaccine
therapy, recommending ether as practical,
harmless and inexpensive. Reim treated 37
cases with ether to which he added camphor ;
after 5 or 6 daily injections the paroxysms
were reduced from 24 and 28 to 6 and 8. and
no bad results were seen even in infants. Mag-
ni reported ether treatment of 35 children with
17 cures, 8 improvements and 9 patients show-
ing no change. Graesser gave a detailed re-
port of 21 patients, ranging in age from 2
months to 3 years ; there were 3 complete cures,
14 showed improvement, and 2 did not show
any effect; average duration of the disease was
about a week though improvement showed
after the second or third day. Redo was im-
pressed by the coincidence that pertussis had
been entirely cured in 2 children given a gen-
eral anesthetic for an operation. He treated
whooping-cough by intramuscular injections
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
97
of ether to a total of 5 c.c. per injection. Panayo-
taton reported on 25 cases, giving 2 c.c. ether
on alternate days; all cases cured in 12 to 15
days.
The first report in the American literature
on the use of ether for the treatment of whoop-
ing-cough was made by Mason, in 1923, when
he published his results with 26 patients, aged
from 6 months to 8 years, of whom he reported
60% stopped coughing and were apparently
cured, 24% definitely benefited, and 16%
failed to respond or became worse. Drake re-
ported several cases treated with very good re-
sults ; vomiting ceased after 1 or 2 injections
and no serious complications followed in any
of the cases. Abraham Tow reported 82%
of his cases, or 50 out of 61 children, improved.
The ages varied from 20 days to 7 years, and
he stated that the number of paroxysms were
reduced, their severity lessened, the appetite
improved, the children slept and rested better.
He reported 9% of his patients as having local-
ized abscesses and necrosis of tissue. Alton
Goldbloom reported favorable results but
favored use of the ether by rectum to avoid
abscess formation at the site of injection. El-
good summarized his experience with the ether
treatment by saying : “Ether will check com-
pletely 25%, fail completely in 25%, and give
considerable improvement in 50% of the cases.'
Guinea in a report on 302 cases treated by this
method classified 250 patients, or 83%, as defin-
itely cured, 35 patients very much improved, 17
not relieved; no complications. He gave from 3
to 5 c.c. of ether on alternate days. Pollock
stated that in his 107 cases treated by ether in-
jections 50% showed improvement after second
injection, within 3 days, and 20% after the third
injection. Summers was enthusiastic over his
experience with private patients, stating that
the ether treatment had given gratifying re-
sults, especially in cases with complications.
In families where there was more than 1 child
with pertussis, he attempted to make com-
parisons of results with ether and vaccine ther-
apy. The child with the more severe symptoms
received the ether injections. In his opinion,
in all cases ether proved the more effective
treatment. He noted a response to treatment
usually after the first injection. Magliano and
Newman reported favorable results but in a
very small number of cases.
Reporting on the treatment of whooping-
cough by injections of ether, in July 1928, we
pointed out that on account of the high per-
centage of necroses it did not seem a desirable
treatment. Later experience with a modifica-
tion in the method has caused us to change our
opinion, and we are making this report on 104
cases of whooping-cough treated at the City
Dispensary, Newark Department of Health, be-
tween May and August 1929, by intramuscular
injection of ether in oil. Our children varied
in age from 2 months to 10 years. Realizing
the uncertainty of positive early diagnosis of
whooping-cough, we accepted for our ex-
periment only those cases in which the diag-
nosis was most certain.
Our results are classified as follows : Im-
proved— where the child showed a definite de-
crease in the number of coughing paroxysms,
whooping and vomiting spells, an increase in
appetite, with more restful periods during the
day and night; where the duration to date, in-
cluding the period of treatment, was not more
than 3 weeks. Unimproved — where the child
appeared the same or worse than when the con-
dition was first seen. Slightly improved —
where the number of paroxysms of coughing,
vomiting, and whooping were decreased in
number but not sufficiently to warrant a feel-
ing of satisfactory treatment ; where the child
appeared improved but the period, of duration
was more than 3 weeks.
Of the 104 patients, 76 (74%) were termed
improved; 23 (22%) unimproved; 5 (4%)
slightly improved ; 94 patients received the
usual dosage of 1 ampule containing 1 c.c. of
ether plus 1 c.c. of oil ; 10 patients received
double the dose or 2 ampules. Of these 10
patients, 5 were among the improved, 5 among
the unimproved. Among the entire 104 pa-
tients treated, no abscess or necrosis at the
area of injection was seen. Our procedure
was to cleanse the skin with 5% tincture of
iodin, wash off with 95%> alcohol, and give the
injection deep into the buttocks, alternating
sites of injection. No other medication was
allowed.
Tt was noted that in the colored children
treated the substance injected remained for 48
98
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
to 72 hours; in some cases as a circumscribed
hard area. In white children, the material was
absorbed within 24 hours.
Among the improved cases, 68 patients re-
ceived not less than 4 nor more than 7 injec-
tions. Among the unimproved, the 23 pa-
tients received from 4 to 11 injections.
We were unable through the Dispensary to
follow up our patients to see if the improve-
ment was lasting. The mothers failed to re-
turn as directed ; only 16 returning to state
that no relapse occurred. All the children bore
the injections well. The age of the patient did
not seem to enter into the matter of improve-
ment or dosage.
In reviewing our experience with this
method of treatment, we naturally pause at our
failures and try to account for them. Why one
case of severe whooping-cough should respond
to treatment while an apparently milder case
does not, is a problem that still confronts us.
To attempt to explain the success or failure
of any treatment in any given disease one must
turn to the pathology of the disease and to the
method of attack by the treatment on that dis-
ease. Of the pathologic anatomy in whooping-
cough, Osier said — “whooping cough itself has
no special pathologic changes”. Holt and How-
land say that the only constant lesion of per-
tussis consists in a catarrhal inflammation of
varying intensity which affects the mucous
membrane of the larynx, trachea, bronchi, and
sometimes that of the nose and pharynx. The
seat of the irritation which produces the cough
has been variously located by different ob-
servers. The weight of evidence seems to be
that in a great majority of cases the source of
irritation is in the larynx or trachea. Von Herf,
by laryngoscopic examination, found the mu-
cous membrane of the larynx to be swollen
and congested, and that a paroxysm could al-
ways be excited by irritating the mucous mem-
brane between the arytenoid cartilages. Removal
of mucus from the posterior laryngeal wall
shortened the paroxysm. Rossbach reported
negative laryngoscopic findings but found a
plug of mucus in the trachea which he quali-
fied as the cause of the paroxysm.
There has been much discussion as to the
role of the enlarged tracheobronchial lymph-
nodes in the pathology7 of whooping-cough.
Laurence W. Smith, reviewing 3000 case his-
tories, found that in about 80% of cases there
is a demonstrable peribronchial thickening in-
volving chiefly the lower branches of the bron-
chial tree. During the course of the disease,
within 7 to 10 days, there was a demonstrable
diminution in the peribronchial shadow7, as
shown by Roentgen rays. Concomitant with
the peribronchial thickening is an enlargement
of the tracheobronchial lymph-nodes. Smith
reported recovery of the pertussis bacillus cul-
turally in 7 out of 8 fatal cases. He believes
that action of the bacillus is a mechanical one,
interfering with the normal action of the cilia
and possibly leading to their destruction. This
might prevent the normal removal of secretion,
resulting in a continuous irritation and the
characteristic cough. In addition, Smith states
the evidence of a mild toxin, as shown by pres-
ence of a slight inflammatory exudate, by a
lymphocytosis, and by formation of a specific
antibody which produces fixation of the com-
plement.
It seems, therefore, that the accepted patho-
logico-anatomic findings in whooping-cough
consist of a catarrhal inflammation of the
mucous membrane of the upper respiratory7
tract — nose, pharynx, larynx, trachea, and
bronchi with a peribronchial thickening that
results in tracheobronchial adenopathy.
Ether may exert any 1 of 5 actions: (1)
an antispasmodic action on the bronchial spasm ;
(2) it may act as a sedative on the striated
muscle; (3) as an anesthetic to the larynx,
thus diminishing irritability of the mucosa; (4)
as a sedative or anesthetic to the respiratory
center; (5) as an antiseptic and bactericidal
agent.
In our work in the clinic, on a few7 occasions
we noted a distinct ether odor on the child’s
breath 15-30 minutes after the injection. Mason
reported a similar experience with a few7 of
his patients and noted in 1 case that the ether
odor persisted for almost 6 hours. It seems
plausible that the ether when injected intra-
muscularly is absorbed and eliminated or ex-
creted in ether vapor through the lungs.
Audrain in his original report thought ether
by inhalation or by injection exerted an anti-
septic and bactericidal effect. Magni thought
ether exerted its effect by a combination of its
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
99
antispasmodic, febrifugal, and antitoxic ef-
fect ; that elimination of ether through the
lungs allowed the drug to reach the most
minute recesses, attack the bacteria lodged be-
tween the cilia, and affect some moderate de-
struction of the bacteria. Magni also thought
the ether might stimulate phagocytosis or raise
the antibody content of the blood, thus attack-
ing the toxin of the bacteria. Genoese believed
that ether injected has a specific action on the
organisms causing pertussis, as well as relieving
the paroxysm and breaking up a tenacious
sputum. Ether has been used as an antiseptic
to the skin in gynecologic work and Genoese
believed that by its elimination through the
lungs it acted as an antiseptic to the entire
respiratory tract.
In summarising, we wish to bring out the
fact that our results in a moderately large
series of cases seem to bear out the work-
done by other investigators abroad and in this
country. We feel that with this manner of
treatment, ether in oil intramuscularly, there
is no danger of abscess or necrosis at the site
of injection. We feel, that this treatment offers
a definite means of aiding the child with
whooping-cough. We offer no explanation
for our failures other than the fact that since
the treatment was so well tolerated, perhaps
larger dosage should be used. We suggest a
further study with double the dosage or even
larger doses, since it may be that a larger dose
will bring even better results. We further feel
that in a disease as distressing as whooping-
cough, especially in very young infants, any
form of treatment which can be easily admin-
istered and which gives encouraging results in
a fair percentage of cases should be given a
trial.
Discussion
Dr. Arthur Stern (Elizabeth) : About 6 years
ago one of my colleagues asked me whether there
was anything known that would give his child,
and the whole household, some rest at night from
the child's incessant whooping-cough spells. I
spoke to him about injections of ether intra-
muscularly, which I had used in connection with
vaccine treatment with good results but warned
him of possible skin necrosis. When I met the
physician some time afterward he thanked me
for my advice and told me that the relief had
been instantaneous.
In another very severe case o.f, b/.'onchopneu ■
monia, in connection with whooping-cough, treated
by another colleague, the improvement was rapid.
I have since used the injections in bac) cases and
I want to congratulate Dr. Levy on' bis .improve-
ment in bringing to us a staple form in his new
ampules. I have used them a few times in hospi-
tal practice and shall use them again if necessary.
Anything as effective as this remedy is a great
blessing to suffering children and to their parents,
in such a miserable disease as whooping-cough.
Dr. Julius Levy (Newark) : In the first place I
want to congratulate Dr. Finkelstein for the very
fine way in which he has presented this subject,
and to make clear that this work has been en-
tirely done by him. In appraising the value of
this report, an important thing is to be sure of
its reliability because, particularly with whooping-
cough, we have previously heard of a thousand
sure remedies and doctors are justified in being
very skeptical of all new suggestions. I would
emphasize that we should not become enthusiastic
just because we see 1 or 2 children apparently get-
ting better, because whooping-cough itself varies
a great deal in severity and duration, and it is
very easy to believe that the improvement is due
to your treatment rather than to the passing of
time. I think care has been exercised in estimating
improvements and cures, yet I think this skepti-
cism is entirely wholesome. It is, therefore, de-
sirable to collect as many series, and as large
series as possible, in different seasons because all
infectious diseases vary a great deal in intensity,
severity and duration. It is not uncommon to see
several cases of whooping-cough in the same
family, one lasting 3 months and another only 3
weeks, so I think we should be very guarded in
our estimates of any therapeutic measure.
I think it is worthwhile mentioning, on the other
hand, the slowness with which we take on new
methods. Treatment of whooping-cough by ether
injections has been written about considerably for
the past 10 years, and it is still not used very ex-
tensively in America. While I think it is proper
that we should be skeptical, yet, on the other hand,
it should not take 25 years for a new idea to be
accepted by the medical profession. I think the
effect of making a report like this on a very
large series of cases is at least to hasten a trial of
this remedy.
Necrosis is important. We reported 100 cases
and indicated that we thought the treatment
should be given up because about 25% of them
presented necrosis. I discussed this question with
a laboratory worker and he suggested putting the
ether in oil, in ampules, and since then we have
had absolutely no necrosis and no difficulty.
Dr. Finkelstein referred to this peculiarity, that
it does help some patients and not others. Appar-
ently he thinks we have no answer. But Chat
does naturally raise a question in our minds as to
the direct efficacy of ether in the treatment. After
all, it does seem strange that it should be effective
apparently in some cases and not effective at all
in others. There is no question that in some of
the cases it does act almost miraculously, especially
— and this is very important — in some of the very
small infants. Whooping-cough, of course, is a
very grave disease in infants under 1 year. Whoop-
ing-cough and measles cause more deaths under
1 year of age than all the other contagious diseases
combined. It does seem that in these young pa-
tients it is particularly effective. I think that is
one of the most encouraging things about it and
I feel that all of the men who have an opportunity
to try it should 'do so and then report their results.
Dr. F. I. Krauss (Chatham) : I wonder if the
•va.fyfng -reswi>s that. Dr. Finkelstein shows might
not be due to his dosage given intramuscularly be-
100
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1.931
ing too small for the occasional patient. I have not
used ether in this way, but use it continually in
whooping-cough cases, by intrarectal injection in
olive oil, and I find that I can vary the dose from
2 to 10 c.c. once or twice a day according to the
severity of the case. Some require 2 "c.c. and others
10 c.c., and I find that my results have depended
on the size of dose. That, of course, would be a
distinct drawback for the intramuscular injection.
It seems to me it would be difficult to give larger
doses, for it is a painful method of treatment. I
have never used it because I have no public health
work. My treatment of whooping-cough is con-
fined entirely to private practice and there would be
objection by the parents. I would object to giving it
every day or so because of the pain, and we know
how difficult it is to have mothers agree to a treat-
ment that is painful.
Dr. A. 8. Finkelstein (Closing) : I have never
had any experience using ether by rectum. As far
as the dosage is concerned, that is a great problem
in treating whooping-cough by injections of ether
intramusculai ly. As to its being a painful proced-
ure, all patients that were old enough to walk got
off the table a few minutes after the injection and
walked off. The material is absorbed in 24 hours
or sooner. The following day it is entirely absorb-
ed, just the skin prick being noticeable.
As to giving larger doses, in 10 of our cases I
gave 4 c.c.; 5 were improved and 5 unimproved.
In a very small series of cases now going on at
the City Dispensary I have given as much as 6
c.c., which consists of 3 c.c. ether and 3 c.c. oil.
Some showed improvement with 6 c.c., and some
with 4 c.c. did not show improvement.
There is one point that may be of practical help.
In getting the ether out of the ampules it is neces-
sary for the syringe and needle to be cold. It does
not come out of the ampule easily if the syringe
is hot and it is difficult to handle but if the syringe
and needle are cold there is no difficulty what-
ever.
Dr. Hummel : May I ask what preparation you
use; and are the ampules on the market?
Dr. Finkelstein: They are on the market and are
prepared by the Lozier Laboratory. The ether is
put up in a bland vegetable oil similar to peanut
oil; 12 ampules to the box.
NON-PATHOLOGIC OR FUNCTIONAL
HEART MURMURS IN CHILDREN*
Irving Okin, M.D.,
Passaic, N. J.
(From Pediatric Department N. Y. Post-Graduate
Medical School and Hospital, New York City.)
There is a large group of children with heart
murmurs who are not suffering with cardiac
disease. Because this fact is not always kept
in mind some of these children are unneces-
sarily invalided, their activities are restricted
pH — : - ■ V ; ;
*(Read at the 164th Annual Meeting of the
Medical Society of New Jersey, Sectioji mi ;Pfdiw-.
tries, Atlantic City, June 13, 1930.) “ -‘l . •„*’
and they become the objects of undue anxiety.
Aside from harmful neurotic tendencies ac-
quired by a child stigmatized as a victim of
“heart trouble” parents are needlessly alarmed.
The ratio of noil-organic to organic murmurs
is 3:2, based on the study of many thousands
of school children.
Many authorities state that noil-pathologic
or functional murmurs are rare under 3 years
of age. This is not true, for frequently infants I
during an acute infection or a septic blood con-
dition present cardiac murmurs ; usually soft
systolics at the base or apex, which disappear
upon improvement of the child’s general con-
dition. In the septic cases, autopsies have
shown no heart pathology. Peer reports a
case of a baby 10 weeks old with sepsis, who
before death had a very loud systolic murmur
in the pulmonary area and at autopsy no ab-
normalities were found in the heart. Jacob- I
solin reports the case of an infant in whom a
soft systolic murmur was heard over the base '
of the heart at the pulmonic area on the fourth
day of life following a severe intestinal hemor-
rhage on day of birth; with improvement in the
blood picture after treatment the murmur dis-
appeared and remained absent after the eighth
day. This is the earliest case I have found re-
ported in the literature.
I have had the opportunity of observing over
a period of 3 years 50 children with non-
pathologic heart murmurs, in the cardiac
clinic for children at the N. Y. Post-Graduate
Medical School and Hospital. This study is
not yet completed. A recent study at Bellevue
Hospital showed that 4 out of 100 cases of
non-pathologic murmurs became definite or-
ganics after 1 year. None of our series has
shown organic changes, but observation over
several years is necessary in determining the
final outcome of these children. Three of the
children in this series have lost their murmurs
during periods of 6 months to 1 year. One girl
under observation for 2 years with a faint sys-
tolic murmur at the apex and no enlargement of
the heart has been allowed normal activities ; 6
jpouths ago, .with onset of menses, body
G antes'.. ‘ofi tpuUeptv, increase in weight and
height, np mynwr \vas heard and there has
•’beeji/nvne tijp. tp the present time.
Feb.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
101
Types of Murmurs
As a general rule the murmur is a short,
soft, systolic heard over the base of the heart
in the pulmonic area or at the apex. There
are 3 main types :
(1) The cardiopulmonary, or so-called res-
piratory murmurs. These are heard over the
pulmonic area or third to fourth left inter-
spaces along the sternum. They vary with
respiration, being usually loudest at end of in-
spiration and faintest with expiration. These
murmurs, changing with position, become louder
when the child is lying on its back. Even pres-
sure with the stethoscope causes increase or
decrease in intensity. This type is very com-
mon, comprising 20 to 40% of the non-patho-
logic group.
(2) Atonic murmurs are heard best at the
apex and pulmonic areas and have a soft blow-
ing character. They are found especially in
asthenic children and have been attributed to
a vagus atonia. Dioxades has pointed out
that x-ray pictures of these children show a
broadening of the heart shadow to the right.
There may be loss of tone of the heart muscle,
and thereby a relative insufficiency of the mitral
valves is caused. In fevers such as scarlet,
typhoid, grippe, influenza, tonsillitis and pneu-
monia, or almost any acute febrile disturbance,
this murmur is not infrequently found. It may
suggest endocarditis but with convalescence it
disappears. The pulmonic second is never
accentuated in the presence of this murmur.
These comprise the largest group, 60 to 80%.
Hemic murmurs are usually of the same char-
acter as these atonic murmurs and are present
in anemic children.
(3) Venous humming murmurs at the base
of the heart, which Palmer and White have
recently described in detail, are continuous
humming murmurs heard in the supra and in-
fraclavicular regions especially on the right side
and transmitted to the vessels of the neck — best
heard on raising the chin and turning head to
the left. The murmur is similar to the one
of patent ductus arteriosus and must not be
confused with it.
Symptoms. The symptoms are seldom car-
diac, unless the parent, knowing that the child
has a murmur, stresses such symptoms as fa-
tigue, pallor and precordial pain. Practically all
of our cases were discovered in routine physica’.
examinations for other conditions ; mostly pre-
liminary to tonsillectomies, or referred bv
school authorities with note saying that child
has a murmur.
Diagnosis. The diagnosis is established by :
(1) absence of rheumatic history, chorea,
growing pains, repeated acute tonsillitis; (2)
consideration of the general condition of the
child — malnutrition or anemia or an acute fe-
brile condition; (3) size of the heart — no en-
largement demonstrable by physical examina-
tion radiograph, but shape of the heart in the
radiograph is important for if it is of mitral
shape or indicates ventricular hypertrophy ac-
quired heart disease must be considered; (4)
the murmur — its character, time location vari-
ability; (5) absence of accentuation of second
pulmonic sound, which is always present in
acquired or congenital heart conditions; (6)
electrocardiographic studies.
When the electrocardiograph shows a pre-
ponderance of the right ventricle it is assumed
the case is one of pulmonary stenosis, which is
a frequent congenital defect. Also, left sided
defects like patent interventricular defects and
patent ductus arteriosus cause a preponderance
of the left ventricle. Neither sign is found in
non-pathologic hearts.
Differential diagnosis. In congenital heart
disease, besides the electrocardiographic evi-
dence, cyanosis with clubbing of the fingers is
almost a regular clinical finding. The mur-
murs are louder, rougher and longer (extend-
ing into diastole) than the non-pathologic
ones. They are found early in life and are
persistent. A marked thrill over the heart is
frequent and also a chest deformity with ac-
companying general lack of development will
be present.
The acquired murmurs usually have a rheu-
matic history, cardiac enlargement accentua-
tion of second pulmonic sound and a murmur
of definite character, viz : the rumbling, rough
or low pitched murmur of mitral stenosis.
However, the murmur of mitral insufficiency
may be the same as a non-pathologic one.
Treatment
( 1 ) Impress the parents that the child is
not a cardiac but should be kept under ob-
servation for at least 1-2 years; examinations
102
JOURNAL OK THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
at the hospital once a month for a year, then
once every 2-3 months.
(2) Do not make a mental invalid of the
child and do not limit physical activities ex-
cept for the active over-tired child.
(3) Remove any foci of infection; carious
teeth, diseased tonsils and sinuses.
(4) Treat for malnutrition with increased
diet, and tonics to improve appetite; Tr. nux
vomica 5-10 drops before meals.
(5) Treat anemia by removing cause, it
possible ; focal infection, intestinal parasites,
lack of fresh air and sunshine. Saccharrated
carbonate of iron, 10-30 gr. 3 times a day, and
high protein diet have corrected the anemia.
(6) Regulate the child’s life; to bed early
at night, daily baths which tone up the cn
dilation, ample nutritious diet with attention to
the vitamins.
Two illustrative cases and their progress
follow :
Case 1. G. I., girl, aged 4 yr., has a sister
aged 6 who is a cardiac. One year ago she
had grippe. For the past 2 weeks has had
bilateral discharging ears and tender, enlarged
cervical glands on both sides. Temperature
normal. The tonsils were enlarged, inflamed
and cryptic, and the cervical glands bilaterally
enlarged but discrete and slightly tender. The
heart was not enlarged; the rate was normal.
The apex was localized in the fourth space
within the nipple line. A short systolic mur-
mur was heard in the fourth left interspace —
not transmitted. There was no change in the
murmur after exercise, position or respiration.
Her weight was 29% lb. Tonsillectomy was
performed and 9 months later weight was 33l/2
lb. ; glands were not enlarged ; no murmur
heard.
Case 2. E. B., boy aged 12, had pneu-
monia at \]/2 years; pertussis 3y>, measles
at 5, and was subject to frequent sore throats.
Tonsils were removed at 18 months; again at
10 years of age. Three years ago complained
of slight fatigue. He was referred from gen-
eral clinic as possible cardiac, as a murmur had
been discovered on examination. His weight
was 121 y2 lb. General appearance and color
good. Marked dental caries with gum infec-
tion. The heart was not enlarged; rate and
rhythm normal. At the apex a faint blowing
systolic murmur was heard. Advised removal
of carious teeth and no restrictions in activi-
ties. Ten months later his weight was 123 lb.
The carious teeth had been removed. No mur-
mur was heard.
Discussion
Dr. Stanley Nichols (Long Branch): I am sure
we are all very thankful to Dr. Okin for this very
comprehensive paper on a very much neglected
subject. To me, this is the greatest problem we
have in the field of children's heart disease. There
is no question that thousands of children in this
country are unnecessarily made, not only physical,
but mental, invalids by some one pronouncing a
heart murmur to mean heart disease. The men-
tal part of it is the worst because the physical
part may disappear.
The proportion of these functional to organic
cases is so large that it justifies the doctor hearing
a heart murmur in calling it non-pathologic, if he
has any doubt. If he is not sure in his own mind
the first time he sees the case, after taking the
history and listening to the heart, that it is a
definite acquired or congenital murmur, he may
wait 6 months or a year before deciding this point
— making repeated examinations meanwhile. He
is thus easing the mother's mind and at the same
time making sure. 1 would say, roughly, that 60%
of heart murmurs can be classified at the first
visit, but certainly 20 to 30% will take 6 months
or a year to prove. A mental fear may be very
serious. It does not bother the child very much
unless he becomes a mental invalid, but a
mother immediately takes fright. You can say
to her that her child has some tuberculous con-
dition, or nephritis, and while she will be mod-
erately alarmed, she will not be half as frightened
as by the report of a heart murmur. The reason
for this is the impression that heart disease has
made 6n the human mind. For instance, she
reads that some friend dropped dead in her home
last week, or someone in a prominent position is
well today and gone with heart disease tomorrow.
So, while perhaps 90% of heart cases die of a lin-
gering illness, heart disease to the public means
death and probably sudden death. Mothers gen-
erally have that idea firmly in mind, and so is
created a mental invalidism, something that is
difficult to get rid of. We should be absolutely
negative on heart murmurs being organic until we
are absolutely sure of our ground. Dr. Okin has
covered that point and has emphasized that these
children should be followed for a period of 5 years.
How long should a non-pathologic murmur be fol-
lowed? If in 6 months to a year you have de-
cided that it is a non-pathologic condition, you
should say to the mother — “This shows no evi-
dence of being organic.” It should be remem-
bered that you have to treat the child and the
mother, 'and the mother is really more important.
After you have studied the scientific problem, then
study the mother. If she is well balanced and not
inclined to take alarm, you can tell her that if the
child develops any symptoms she must bring it
back. Unfortunately, many mothers are not so
well balanced. The very words “heart murmur”
cause them so much mental fright, that it is bet-
ter to say to the majority of mothers that they
had better return with the child every 3 to 6
months so that you can watch the condition and
keep their fears allayed. This may have to con-
tinue throughout childhood. You will be accused
of wanting to fill up your office at the public ex-
Feb.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
103
pense, of course, but you will be doing justice to
the patient and keep this child out of the hands of
some one who may invalidize it and give unneces-
sary treatment. If you discharge a nervous mother
and child and say that the condition is not organic,
in 3 months to a year some other doctor will hear
this heart murmur and start the ball rolling again.
The routine treatment unfortunately given to
many children with heart murmurs is simply to
administer digitalis, and not let the child do very
much. There is only too often no careful study
made to find out whether it is a congenital, ac-
quired, or non-pathologic murmur.
'The pediatricians are peculiarly equipped to han-
dle these heart problems, more so than some car-
diologists, because they often have more interest
in the child heart and see it from a different view-
point. Far too many cardiologists think that the
child is a small replica of an adult, and treat its
heart accordingly. If we follow the treatment Dr.
Okin has outlined, we will be doing a very satis-
factory service, and perhaps cure what might
cause a mental invalidism to the mother and some-
times to the child. While you may say that is a
part of the art of medicine rather than the science,
you can first practice the science, making sure
the murmur is not pathologic, and then practice
the art, which is to keep the patient’s mind free
of mental invalidism.
Dr. D. J. M. Miller (Atlantic City) : I did not
hear the essayist’s paper and heard only part of
the discussion, but I did hear the doctor say, and
I would like to endorse the fact, that there is a
great amount of unhappiness caused by the knowl-
edge that a child has a cardiac murmur. You
pediatricians have seen cases sent in, particularly
by school doctors, and the mother in a great state
of apprehension because a murmur has been dis-
covered. I only want to say this, that in my own
experience the most common so-called functional
or non-pathogenic heart murmur heard in chil-
dren is the pulmonary systolic murmur which is
heard at the base of the heart, usually on the left
side, sometimes on the right and sometimes even
down as far as the apex. I think it can be safely
said that if the child has a heart murmur, par-
ticularly in that situation, and there is no other
sign of heart disease, the child can be dismissed
without further examination and without further
following up of the case. The mother's fears can
be allayed and the child can be allowed to go on
with its ordinary amusements and exercises. Too
many children are hampered because they have a
heart murmur.
There is another functional murmur heard
which is generated in the lung, the so-called car-
dio-pulmonarv murmur: definitely connected with
respiration, I think. If that feature is noted I
think those murmurs also can be dismissed with
perfect confidence that they are not organic.
Dr. F. C. Johnson (New Brunswick): I would like
to second very strongly what Dr. Nichols said
about these cases, and what Dr. Okin probably
believes about the treatment of the family, but
I would like to go even further; I wonder
if very often, with certain people, it would
not be legitimate to say nothing at all about
these heart murmurs which you are convinced are
non-pathologic? It may be that the patient will go
to some one else who will bring the condition home
forcibly and want to treat it as a heart disease,
but why not let some of these murmurs go until
they are perhaps outgrown, the patient being seen
regularly several times a year, as many of our
patients are coming to be observed? There might
be a great deal of nervous strain saved if func-
tional murmurs were not mentioned.
As to the classification of these cases which are
called non-pathologic: is the condition of the heart
in which the ring is dilated and the murmur pro-
duced by relaxed muscle or ring strictly non-
pathologic? It is not a normal heart but it is not
the function of the cardiologist to treat it. The
treatment is not heart treatment, at all, but general
treatment of the patient; so that this condition
should be, 1 think, distinct from those cardio-
respiratory and other non-pathologic functional
murmurs which do not amount to anything.
Has there ever been anything gained by taking
an electrocardiogram of the cases which were
clinically thought to be non-pathologic?
Dr. Irving Okin (Closing); In this group, these
electrocardiographic studies were made more from
a scientific than a clinical viewpoint and certainly
we do not do them in private practice. I have
never seen a case where the electrocardiographic
study alone made the diagnosis.; it was made
clinically every time.
As to considering them as a pathologic group,
that was the point I tried to bring out, that it
was not heart disease or rheumatic disease. We
consider the rheumatic heart as a part of the
rheumatic disease. We do not feel that these
cases are definite organic cardiacs. The valves
are not sclerosed, there are no inflammatory
changes in the valve, and at autopsy, where the
patients have died of other conditions, there was no
cardiac pathology.
Do not treat the heart but treat the general con-
dition and by building up the whole system and
bringing the child into the best possible state of
health you will probably bring the heart muscle
into the best possible state of health at the same
time.
Dr. Miller said we should dismiss these children
once we have made the diagnosis, and Dr. Johnson
suggests that we should say nothing to the parent
about the condition. I have had one unhappy ex-
perience. One day, while I was away, another
doctor was called to one of my patients and the
family was very much worried because he found
this murmur and told them about it, and of course
the whole cycle about which we have been talking
was started. I assured them that I had heard
the murmur and that it did not amount to very
much. I think you should mention it to the
mother to protect yourself.
INTEGRATION OF THE CHILD*
Ira S. Wile, M.D..
Mew York City
The practice of pediatrics has altered ma-
terially during the past generation. A consid-
eration of the various types of work now in-
volved in the care of the young demonstrates
the tremendous variety of interests and func-
tional organizations. One need but enumerate
*(Read at the 164th Annual Meeting of the
Medical Society of New Jersey, Section on Pedi-
atrics, Atlantic City, .Tune 13, 1930.)
104
JOURNAL OF THL MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
such problems as are involved in child hygiene,
prevention of blindness, growth of boarding
homes, development of pre-natal work, pre-
school examinations, medical inspection of
school children and the inception of various
types of clinics for mental hygiene and for
meeting the problems of exceptional children.
One notes the existence of a large variety of lay
organizations dealing with juvenile problems or,
indeed, with specific phases of work with chil-
dren. Under this head are found, for exam-
ple, groups organized for fostering clinical ser-
vices in settlements and schools, for promoting
welfare during infancy, urging diphtheria and
tuberculosis prevention in communities, as well
as lay groups interested in the moral status of
dance halls, pool rooms and theatres ; and
those who are specially cognizant of the needs
of industrial hygiene, limitation of child labor,
special classes for handicapped children and
who propose various modes of elevating child-
hood from the education of parents to their
abolition. This variety of interest in juvenile
Avelfare has developed without serious partici-
pation of pediatricians.
Today one finds a shift of emphasis from
specifically physical problems to those that in-
volve intellectual activities, emotional adjust-
ments and social adaptations. It still remains
common to have the child considered in terms
of specific phenomena. As in a previous gen-
eration there was stress upon excessive cigarette
smoking, today there is a fear of too great
fondness for liquor or for movies. There is,
however, a larger degree of attention given to
juvenile habits that are deemed undesirable.
The viewpoint has altered in that today many
habits are viewed as subversive of the finest
growth of the personality of the young, and
not merely as unpleasant for the family or the
community. One need but enumerate such
difficulties as sleeplessness, worry, excitement,
lack of concentration, school failure, mental de-
pression, fear and anxiety, irritability and tan-
trums, sex delinquencies, disobedience and
cruelty, to appreciate some of the new ele-
ments entering into consideration of child be-
havior. Fidgetiness, lying, stealing, vagrancy,
fantasy, frequent change of occupation, men-
tal retardation, drug addiction, the epilepsies,
have become as significant in the welfare of
children as the more readily noted difficulties of
speech, sight and hearing or even such seem-
ingly physical behavior as scoliosis, enuresis,
pavor nocturnus, chorea or syncope.
The layman no longer regards behavior as
accountable on the theory of original sin or in-
heritance from ancestors who cannot voice
their own defense. Pediatricians are inade-
quate in their medical service if they dwell en-
tirely in the seclusion of somatic diseases. They
must take cognizance of all behavior — asocial,
social or antisocial. They should treat all
aberrant forms of reaction — and all diseases
are reactions in and through living. All human
behavior, particularly in its juvenile phases,
represents a totality of reaction. Is the pedia-
trician to treat the child who reacts or merely
some of his reactions?
This leads me to ask: what is a child? From
the common viewpoint it is merely an offspring
in relation to his parents. On the other hand,
a child even as a physical entity has primary
relationships in terms of physical activity, in-
tellectual life and social adjustment construed
as community values. Is a child merely to be
viewed in terms of his body? Is he an agglom-
eration of muscles, viscera, glands and nerves?
Is he merely an anatomic organization?
Patently, anatomy, in itself, does not consti-
tute the essence of the child or there would be
no distinction between the cadaver and the
functioning organism. The child may be
definitely viewed in terms of his anatomy but
his physiology is of far greater significance. Is
he, however, merely a congery of physiologic
systems organized to sustain the vital processes ?
The distinction between hypothyroidism and
hyperthyroidism indicates the significant dif-
ference between the physiologic activity and
the mere anatomic presence of an organ. Ab-
sence of the thyroid gland, with its resultant
cretinism, evidences one phase of physiologic
dependence upon anatomic presence. Func-
tional stability of the heart is vital to the total
welfare of the child but the presence of a con-
genital cardiac anomaly that necessitates a com-
pensatory modification of function does not al-
ways disturb the total equilibrium of childhood.
Consciousness of the cardiac dysfunction may
be more devastating than the lesion and its
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
105
physiologic deviations. The child obviously is
more than his basic somatic structure.
Is the child to be viewed entirely as mind?
Are the primal instincts, his emotions, intelli-
gence and imagination, his capacity for mental
activity, whether in learning or adaptation, to
be regarded as his totality? Patently, instinc-
tive activity is inherent in child biology but his
social existence involves regulation of the in-
stincts for practical living. Mere knowledge
of the intelligence of a child does not give a
picture of him any more than knowledge of
the size of his hand gives sufficient informa-
tion concerning his capacity to hold a job. No
one can gainsay, however, the important part
that mind plays in the total configuration of
child life. Psychic life involves the instinctive,
emotional, intellectual components, but as in-
teracting rather than mutually exclusive fac-
tors.
Laying aside for a moment the biologic
manifestations of a child in terms of anatomy,
physiology and mental activity, there are very
definite social values which constitute an es-
sential part of child reactions in health and in
illness. Some people refer to the soul of the
child as though it were a thing apart from his
mundane life. No one would assume that
religion, social sentiment and spiritual values
represent the summation of child life, even
though they cannot be disregarded as vital facr
tors in his living. The social bases of his per-
sonal welfare are deeply founded in the physi-
ology and psychology of the child. Pie is what
lie is by virtue of the totality of factors enter-
ing into his unitary completeness. His entire
personality is created by the internal interaction
of all that he is in response to all that he
touches in his environment and to all of the
environment that impinges upon him.
The child is a unit in function. His activity!
is the expression of his total reaction as a
biologic social being. The child, as an ab-
straction, has very little practical value to
physicians save for the purpose of establising
theoretic norms of height, weight, metabolic
activity and the like. Each child is a unit in his
own constitution, in his inheritance, in his en-
vironment. His life depends upon the unified
reaction of all the endogenous and exogenous
factors that affect him. There is an inter-
relationship between a large variety of seem-
ingly unrelated elements. Whatever behavior
he manifests represents the integration of all
his functions. One cannot differentiate his
physical and mental systems as though they
were acting in parallel or possessed independ-
ent activity. They are only phases of his total
personality. Walking, talking, dreaming, creat-
ing are not phenomena isolated from respon-
sive social living. One may consider the large
variety of behavior patterns of childhood from
any one of several angles but their meaning
depends upon their relation to the possibility
of securing harmony in environment. Abnormal
behavior represents disharmony whether from
causes primarily somatic, psychic, or social.
Abnormality in structure or jn function car-
ries with it no certainty of type reaction. The
behavior response is unpredictable because
neither structure nor function constitutes the
sole dominance of the being. The vital or-
ganism is not essentially behavioristic and so a
definite stimulus does not always determine
the identical response. I may illustrate this by
considering myopia. There are, of course,
varying degrees of myopia but one cannot pre-
dict the behavior reaction of a child even when
the degree of myopia is known. One child, for
example, , with a moderate degree of myopia,
will complain of headaches, fatigue, refuse to
study and perhaps play truant. Another child,
with the same degree of visual difficulty, will
apply himself more assiduously, strive to at-
tain high standing and regret school vacations.
A third child thus handicapped will do more
school work than is necessary, but will seek an
outlet for his activities by recourse to stealing,
or by day dreaming or creative work along
lines involving little visual application. The
behavior variations of these children depend
upon elements of personality that are not bound
up in the myopia. Amputation of a thumb
takes from a child something more than 2
phalanges. Who can prophesy his response to
this mutilation? It may totally disorganize the
harmony of living for a child, particularly if
he has aspirations to be a baseball pitcher. Re-
moval of tonsils is not to be regarded as a slight
physical operation without effects upon the total
reactive organism of childhood. One need but
think of the unexpected and unpredictable post-
io<;
JCH RXAL or THE MEDICAL SOCIETY OE NEW JERSEY
Feb., 193T
tonsillectomy neuroses, phobias, choreas and
the like as evidence that the operative proce-
dure involves more than a physical trauma.
One cannot even state what a child will do it
his foot is stepped on ; much depends upon
when, where and by whom.
'Hie interaction is very observable in the re-
actions of children to psychic distress. The
physical reactions of fear, rage, love and the
like are manifest in a vast variety of somatic
expressions which greatly disturb normal
adaptation. The hysterias of childhood, the
psychogenetic epilepsies and the psychoneuroses
bear witness to the involvement of the somatic
systems as an expression of diminished har-
mony in the total psycho-physical life. Fear
produces disturbances of muscular and glandu-
lar function, and functional disorders of the
heart or gastro-intestinal system cause fear
reactions. The adrenal gland affects and is
affected by psychic reactions of frustration
and anger.
I have stated that intelligence is not the main
factor in the organization of child life. No
one denies that the possession of a high or low
intelligence quotient is a matter, of importance.
The intelligence quotient, however, does not
reveal qualities of leadership, persistency, in-
dustry, artistry, humor or social adaptability
which are vital constituents of personality. The
behavior reactions of a moron, an imbecile or
a superior-minded child are not to he evaluat-
ed entirely in terms of their intelligence levels.
One cannot predict immediate reactions nor
later success in life with certainty, utilizing the
intelligence quotient as the sole basis for judg
ment.
Intelligence is hound up to no small degree
with many physical states. The absence of a
thyroid gland, for example, makes the intelli-
gence level exceedingly low. Presence of deaf-
ness or mutism appear to lower intellectual
potentials. Hemiplegia, mongolism, chorea,
encephalitis affect mental potentials. Fear of
injury or personal harm may interfere with
the adequate employment of existent intellec-
tual potentialities. The relation between social
adjustment and intelligence involves more than
a definite level of intellectual capacity. Social
harmony in contacts is not assured by keen
mental powers of learning. The relation be-
tween character and intelligence involves the
consideration of non-intellectual components.
In the last analysis, intelligence is relative. A
child may be intellectually capable in one school
and intellectually incapable in another school
having a much higher level of pupil selection.
Intellectual adequacy or inadequacy, however
in so far as it is a part of the total expression
of juvenile behavior, is definitely less import-
ant than emotional stability.
The emotional life of a child is conditioned
by inherent mechanisms upon which I need not
dwell at this particular moment. It is suffi-
cient to say : “The motor trend of the emotion
dominates conduct.’’ The child is a reacting
organism. Doing is more important than think-
ing. I shall not discuss motivation or life
goals because it would require too much time
to explain the psychodynamics of Freud, Jung,
Adler and others who dwell upon the psy-
chogenetic domination of human activity. Nor
shall I stress the conditioning theories popular-
ized by Watson or the foundations of an ap-
proach through the social psychology of Mc-
Dougall or Trotter. I wish to be more generic
in my approach to the emotional drives, regard-
less of their nature.
To put one’s self across in the community
and to gain personal satisfaction is especially
significant for child life. One may recognize
potent emotional factors entering into person-
ality as they grow out of definite instinctual
qualities of life. There are the emotions that
grow out of the ego, the herd and the sex in-
stincts. The feeling tones, whether in terms
of pleasure or pain, sinlessness or sinful guilt,
in so far as they affect the person as a unit and
as they affect his relations to the groups with
which he must live, deeply affect his total re-
actions. The sexual instincts affect both the
ego and the herd trends and are inherent in
the somatic and psychic organizations of the
child. These emotional components vary in
their activating forces in accordance with their
dominating presence in the conscious and un-
conscious life.
In childhood, the pressures upon the ego
are most severe. The entire scheme of habit
formation for social living involves a modifica-
tion of the ego trends and the restriction of
native biologic impulses in order to attain a
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
107
social harmony without too great a sacrifice of
the ego. The entire training period of child-
hood therefore involves tremendous molecular
readjustments of the personality. There are
involved coordination of the brain and muscles,
the cerebrospinal, sympathetic and parasympa-
thetic systems, the intelligence and emotions,
out of which grow the variety of attitudes and
powers, including the ability to make adapta-
tions, the willingness to do so, and finally, the
determination to secure the harmony most pro-
ductive of satisfaction in every realm of action.
The child seeks security and love, companion-
ship and harmony in terms of an internal sense
of success and achievement with an increasing
amount of independence and power in external
relations.
I am emphasizing that the child as a unit
possesses a physical life, an emotional life, and
an intellectual life but that these are thoroughly
interacting and merge finally in an expression
of social life through which self-realization
must be secured. Child behavior always has
meaning ; it is symptomatic ; it has purpose. The
feeling of inferiority, as stressed by Adler, may
arise because of somatic inferiority or by rea-
son of some failure of adjustment in the home,
school, on the playground or in the factory.
The reaction to inferiority may be theft, bully-
ing, emesis, truancy, etc. Conflicts within the
individual child, due to clashes of personal and
social demands and desires, are bound up in
innumerable reactions that are at one time
dominantly physical, intellectual or emotional.
Only for purposes of discussion may one focus
attention upon some specific phases of the
child, because in evaluating and interpreting
child behavior it is essential to synthesize what-
ever has been analyzed in order to grasp the
behavior as total reaction. Multiple causation
must not be ignored as the outgrowth of life
patterns and reactions.
The child is born a biologic unit and his
biology involves, of course, psychology. The
very facts of conception, parturition and lacta-
tion indicate that the child is likewise ab
origine a social unit and his social adjustments
are inherent in every phase of his physical well-
being. The physical animal depends for sur-
vival upon social existence. The declining in-
fant mortality rate demonstrates this fact.
If one discusses moral well-being, one
patently is viewing the child as a social unit.
This requires the consideration of the child in
terms of his efficiency, human compatability and
general adaptability in a dynamic environment.
This involves recognition of the individual per-
sonality of the child. Consideration of juvenile
morals, however, involves judgments concern-
ing his behavior in relation to the ideas, opin-
ions, judgments, sentiments and mores of a
community. Right and wrong are not inherent
in biology. They are not patterned in cere-
bral structure nor in endocrine function. They
are outgrowths of organized social life. Ab-
normal behavior is therefore only a reaction
type that is not accepted by communal judg-
ment. Judgments, therefore, concerning the
goodness or badness of childhood, or of specific
activities, habits or conduct trends, are in
terms of socially determined scales and these
are relative rather than absolute. The efforts
of the child to make adjustments in terms of
his physical capacities, his intellectual potentials
and his emotional systems, bring about be-
havior that is viewed as asocial, social or anti-
social according to time and place considera-
tions. Society by mandate, regulation, tradi-
tion or taboo creates its code by which it seeks
to preserve the mass with little thought of the
individual. An adult world attempts to secure
juvenile conformity by pressures of education,
government, and religion. Each age produces
new conflicts of the older and younger genera-
tions and, as a result, codes of morals are
changed. Childhood is subject to the flux of
its age.
It is obvious that social and economic status,
general and familial, plays a definite part in
the integrated functions of a child. One views
the child as a whole only when his wholeness
involves himself in his setting. Even here the
integration of his functions include what he is
seeking to do to his environment and what his
environment is seeking to do to him. And in-
deed one may add that his integrations involve
also his reactions to the communal estimations
of himself and his responses to the reactions
of various communal groups to his efforts at
special social participation. The inherent bi-
ology of a child varies as an instrument of
stimulation and response under conditions as
108
JOURNAL OF THE 'MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
found at home, at school, at church, at play
and at work.
I have said sufficient to indicate that the
pediatrician must learn to view the child as a
whole rather than to pass quick judgment upon
his behavior. One recognizes the effect of
fatigue upon behavior as well as the modifica-
tions of conduct due to the prodromes of con-
tagious diseases. The physician appreciates
that profound alterations of behavior may re-
sult from a large variety of physical causes.
I need but refer to club feet, birth traumas,
blindness, convulsive seizures, poliomyelitis
and encephalitis. There is a vast distinction
between causation and concomitance. A syphil-
itic child may steal but that does not prove
etiologic relations any more than the coexist-
ence of diabetes and wanderlust, tuberculosis
and masturbation, flat feet and tantrums or
endocarditis and lying. Where one thinks in
terms of the possible causes of school failure,
delinquency, homosexual practices, mental dis-
eases or physical inadequacies, the pediatrician
must shift his viewpoint so that he views the
child as an integrated personality. The physical
sequels of diseases are not limited in their
effects to the specific organs that they may in-
volve. Faucial diphtheria may damage the
kidneys; intestinal typhoid produces delirium
and even psychoses ; encephalitis may com-
pletely transform a personality from a socially
acceptable type to one that is so dangerous as
to require permanent institutional care. The
symptomatology of numerous diseases involves
more than the somatic manifestations of the
underlying physical processes. Why, for ex-
ample, does one child respond to a mild fever
with headache, malaise, disobedience and tan-
trums, while another child evidences increased
activity, marked volubility, together with sub-
missiveness and a general acquiesence to paren-
tal and medical requests. These differences in
behavior are determined by the total functions
of the children. The countless deviations of
children from a theoretic norm depend upon
their totally integrated reactions. The whole
child, for example, has a disease even though
the main systomatology appears to be localized.
Treat the child, is almost a pediatric slogan.
Health in children has wide connotations. It
is not to be regarded merely as the absence of
defect or disease. Physical perfection in itself
is not a rational goal of life and the full at-
tainment of remedial work on children does not
guarantee completeness of living. Fulness of
life is a positive characteristic and is more than
being full of life. I have shown that anatomy is
subordinate to physiology; that physiology
conditions psychology ; that psychology fash-
ions social reaction and that social reaction de-
termines morals. This does not mean that
these elements are segregated in the personality
of children. To the contrary, they constitute
such an interconnecting mechanism that the
child can be considered as a unitary being only
by recognizing the continuous interweaving of
these factors in and upon his personality. The
whole child is more than the sum o'f his con-
stituent parts. The health of the body, mind
and spirit is resolved into what Williams de-
fines as “the quality of life that renders the
individual fit to live most and serve best”.
The integration of the child calls for a larger
degree of attention by the pediatrician because
it enables him to interpret the child as a bi-
ologic-social unit. He cannot practice modern
pediatrics intelligently ^without an appreciation
of his part in guiding and forming juvenile
characteristics. He is not a dispenser of drugs
nor only an adviser of sunlight, fresh air and
an adequate dietary ; he is a source of ideas of
child training, a guide to useful habit forma-
tion, a counsellor on human relationships, an
authority on mental hygiene, and preventive
medicine. As a scientist he reveals the art of
living and reconciles it with the theoretic scien-
tific basis of life. His contact with homes,
with children, with parents, with school and
with the community give him a tremendous ad-
vantage in approaching the problems of the
juvenile population. His major medicosocial
service is attainable, however, only when he
sees children as individuals and as parts of a
communal organization. He should grasp the
idea that the child oft-times is in conflict with
the regulations and the adult rules of life, but
ever is seeking to find satisfaction in the en-
joyment of his inherent biologic demands and
urges, while endeavoring to function in his
world with the least internal conflict. The
pediatrician has a prominent role as physi-
cian and specialist, friend, guide and conn-
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
109
sellor in influencing the integrations of the
child. To interpret the protean world to a
child and to interpret the child to his many-
sided world is a social pediatric function whose
integrative value is paramount for fostering a
socially adjusted life with a harmonious growth
of personality and an effective individuality.
Discussion
Dr. Julius Levy (Newark): We cannot let this
very brilliant and philosophic talk go by without
some comment. For many years, those of us who
have known Dr. Wile have known him as a genius
for bringing together the many thoughts and ideas
that are brought out from time to time and giv-
ing them a logical basis, a sequence, and an orien-
tation which is often lost in this busy world.
I think one of the great contributions Dr. Wile
is making today to pediatrics, and particularly in
the field of mental hygiene and psychology, is this
insistence that the ideas that are brought out from
time to time, and the emphasis placed on certain
statements or viewpoints, are merely single re-
flections of some general idea. One of the great
dangers in medicine has been that in every gen-
sration we act as if somebody had rediscovered the
sause of all things, and we wildly follow one idea,
forgetting everything that has been said for the
previous hundred shears only to be brought up
short by a thorough student and shown that there
is no need of neglecting all that has gone before.
I think there is a particularly important lesson
in Dr. Wile’s approach to this question. One hesi-
tates to use the word practical after Dr. Wile’s
profound elaboration of this problem, but those
of us who are more simple in our work adopt very
fully Dr. Wile’s idea that when children are
brought to us for anything at all there is a mag-
nificient opportunity to try to understand fully
the child and the family environment. I know
that the pediatrician who has permitted himself
to grow into something more than an infant feeder
has found his greatest encouragement, his great-
est influence, in trying to help children to adjust
themselves better to their environment and to help
mothers to make this adjustment easier by under-
standing their children.
Another important point is Dr. Wile’s casual
reference to the great number of lay organizations
that have developed an interest in the child. There
is a group that is very well intentioned but whose
familiarity with children is only from yesterday
and they make one phase of child life dominate the
whole field of child care. You know it is very
easy for a Viennese to come here and, by tickling
the intellectual palates of our women, to be readily
invited into the homes of America, and by prop-
erly engineering newspaper publicity made to ap-
pear that he has discovered the whole secret of
child management and child care. Child care has
another duty: that of giving the proper place to
many of these new ideas.
Dr. Wile has made a brilliant contribution and
we are certainly very much honored in having him
here.
Dr. Stanley Nichols (Long Branch): I have al-
ways said that men who understand children
should lead in this field of work and Dr. Wile, as
any one will confirm who has sat at his feet, lias
gone into the child mind and outdone the psy-
chologists. Anyone who can should go up to Mt.
Sinai Hospital at 3 o’clock on Wednesday after-
noons and see his work in progress. You will
never do so without learning something that will
be of value in your practice. The subject is so
large that we pediatrists stand in much the same
relation to it as the general physician does to the
pediatrists. We are as the blind leading the blind,
but perhaps we can get one eye open if we apply
ourselves. The simpler adjustments in family life
we can carry out. I sincerely hope that the com-
mittee’s recommendation, of having a course in
this state, will be carried out so that all practi-
tioners may take a course in children’s mental ad-
justments.
In the matter of keeping this subject in the
hands of medical men, the question immediately
arises — How many men can we furnish in this
state to keep the child guidance clinics going?
At the present time there are not enough such
doctors. We have psychiatrists running child
guidance clinics and they often approach the prob-
lems, not as Dr. Wile does, to integrate the child,
but as a neurologic or mental problem. When we
refer the child to such a clinic we are likely to get
a neurologic report rather than some definite rec-
ommendation as to how we shall solve the family
difficulty. If we had more pediatrists interested
in this field, such as the members of the commit-
tee that Dr. Levy is serving upon, who would give
more time and attention to that subject, we could
have a system of state family adjustment clinics
to make such studies and recommendations, as
well as men who, in private practice, would solve
the more difficult problems as Dr. Wile does in his
private practice in New York. We all know that
it is a question of educating the mother after we
have first studied the situation. We often wish
that we could do what they do in unhappy mar-
riages, and put another mother in her place, be-
cause that sometimes seems to be the only solu-
tion.
Dr. Samuel StaXberg (Atlantic City) : Dr. Wile’s
work appeals to me as a general practitioner, es-
pecially as he approaches the subject, not so much
from the philosophic or psychologic standpoint as
from that of the general health of the child, and
the general diseases which may assail it. Dr.
Wile’s work is especially valuable because of the
fact that child delinquency and crime have been
on the increase, and I think no greater work has
been done in the realm of pediatrics than that of
Dr. Wile in the last few years.
Dr. F. I. Krauss (Chatham) : I might quote my
views in the form of a paradox, in saying that
this question is harder than it seems and yet not
so hard as it seems. When one listens to Dr.
Wile, one feels very inadequate at first in his ap-
proach to the : subject, but on second thought it
is not so hard because 99% of it is common sense
and the other 1% for the general man is technical
knowledge. Our greatest difficulty in private prac-
tice is to teach the mothers that children are en-
titled to a certain amount of liberty. From the
m,oment the child is able to toddle around, after the
first year has passed during which the child is the
tyrant of the family, this child must conform to
what the parents want it to do, and as soon as
it begins to interfere with their liberties and de-
sires, discipline begins; whereas, discipline should
have begun in the first few weeks of life. It is
usually delayed until the damage is done and then
the conflict arises in the child’s mind as to how to
adjust itself to the social status. I always em-
phasize to parents that they shall give the child
110
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
such liberty as is compatible without interfering
too much with social adjustments, and when the
child must be disciplined or corrected in any way
let the punishment lit the crime; consider it from
the child’s viewpoint, how the child reacts, and
whether the correction is justified from the child’s
standpoint. Usually that helps a great deal in
giving the mother an idea how to handle the child.
Our greatest trouble, of course, is with the first
child or only child of the family. By far the best
thing is to have several children in the family so
that the children can work out their social adjust-
ments as they go along.
I am glad that Dr. Wile brought up the sub-
ject of fear — fear following operations, particu-
larly tonsil operations. We speak of these as
minor operations. I regard them as major opera-
tions. A description of the way the anesthetic is
given, the approach to the hospital, etc., are very
important factors in the history. How many times
have we seen a child refuse to eat after an opera-
tion for weeks and weeks; or a child who is fear-
ful of going to a doctor or to a hospital, fear of
the ordinary hygienic things which must be done.
I think these fears carry over into adult life and
turn many people away from the legitimate medi-
cal profession. There are people who still remem-
ber the fears they acquired of doctors and hospi-
tals when they were children.
I feel that doctors as a whole do not need to
know all the various technical treatments which
psychology evolves Let us approach it from a
common sense standpoint, remembering our own
childhood, our own complexes and fears. Most of
us have had some experience in bringing up our
own children, and by putting yourself in the child’s
place you can help the mother, and the child in-
directly in its whole future life.
MEMORIAL TABLET TO DR O. H.
SPROUL ERECTED BY THE HUNTER-
DON COUNTY MEDICAL SOCIETY
AT GLEN GARDNER
Address at the Unveiling Exercises
John F. Hagerty, M.D.,
Newark, N. J.
It is a great pleasure to take part in a meet-
ing of the Hunterdon County Medical Society
in this lovely section of New Jersey. I am
not a stranger in these parts, having become
familiar with this and surrounding country
during my apprenticeship with the late Dr.
Donohue, of New Brunswick, whom many of
you remember. He had occasion to come out
this way frequently on professional work, and
came often, tod, to Finderne, nearby, where
there were always to he found good horses,
and those of you who knew the doctor well can
recall what delight he took in having well bred
stock. I remember a team of well matched
sorrels, each nearly 16 hands high, which he
used to drive here and to Princeton, Kingston,
Somerville, Cranberry, and other places, and
what immense pride and satisfaction he ex-
perienced in driving this handsome pair, and
what admiration they aroused as they went
champing proudly by. We have advanced
rapidly since those days in methods of locomo-
tion. Distances formerly thought great are now
considered slight, and we are able to accom-
plish a great deal more since the advent of the
automobile, but those who were really fond of
horses must often regret their passing.
I had the good fortune, too, to meet while on
the Bellevue Hospital Staff, Miss Alice Schenck,
who was on the nursing staff, daughter of one
of your much respected and venerable physi-
cians of a generation ago, and enjoyed visiting
this lovely representative of the old fashioned
doctor. He was then well advanced in years,
small and frail looking, with snow white hair,
and was very kindly and affable.
1 did not have the good fortune to know well
Dr. Sproul, whom you are honoring today,
but recall seeing him at the state society meet-
ings, where his dignified and courtly manner
made a great impression on me, as it must have
on all the younger men. It is a splendid thing
that you are doing — reminding future genera-
tions of the fine, noble characters who repre-
sented the medical profession in former days
and whose lives of industry and sacrifice and
self-denial endeared them to the people, who
respected and revered them because of their
goodness and helpfulness. These were the
men to whom the present generation of medi-
cal men are indebted for the high and proud
position they occupy in the public esteem, and
which they secured not so much by scientific at-
tainments as by their mdefatigible labors and
the character of their lives. They accomplished
much because of the high regard they had for
their sacred calling and love for their fellow-
man. It was of such men that Holy Scripture
speaks when it says : “Honor the Physician for
the need thou hast of him; for the Most High
hath created him. For all healing is from God
and he shall receive gifts from the King. The
skill of the Physician shall lift up his head
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
111
Feb., 1931
and in the sight of great men he shall be
praised.”
Times have changed and the types of physi-
cian have also, of necessity, changed. The
methods of doing things today are very dif-
ferent, and this is reflected in the manners
and customs of the present day doctor. But,
while less personal and more business-like,
there are still, on the part of the majority of
physicians, the same ideals of service, as shown
by the longer time spent in preparation, greater
intensiveness in study and the wonderful re-
sults being obtained. Just as in manufacturing
and business, older methods have become ob-
solete and newer ways, looking to rapid and
larger results have come into vogue, so, in
medicine, we are endeavoring to secure better
results by sanitation, hygiene and prevention,
as well as by more direct and intelligent ways
of combating disease. In this respect, no one
at all familiar with the efforts of our Boards
of Health, both local and state, can fail to be
impressed by the active and intelligent cam-
paigns against disease and to make living more
healthful and comfortable. The commendable
altruism of the physicians of a former day may
not be so much in evidence, but while this may
be a matter of regret tbe altered financial con-
dition of the laborer and the tradesman has be-
come responsible for such change and no in-
justice will result. At the same time, constant,
scientific efforts, highly altruistic because of
the consequences, are being waged against the
causes of disease, resulting in the prolongation
of human life and under more favorable and
happier circumstances than ever before. One
of the most interesting features of the recent
annual meeting of our state society was a re-
cital of the work of the many agencies of our
state looking to the prevention of human suf-
fering and the conservation of life. .
Unless one has given thought to the subject,
he will have little conception of the debt of
gratitude due to scientific medicine; to the ac-
complishments of those giants of the profession
who have succeeded in wresting from nature
the secrets of disease and made of scourges
and pestilences that formerly ravaged and de-
vastated the earth, only unpleasant memories.
And, most surprising thing of all. is the fact
that these wonderful achievements were ac-
complished so recently by men whose life work
was not ended when many of us here today
had commenced the study of medicine. Time
will not permit detailed reference to these
epoch-making discoveries, but we may quote
Dr. Osier, in his comment upon the blessings of
anesthesia, antisepsis, and bacteriology: “Search
the scriptures of human achievement”, he said,
“and you cannot find anything to equal in
beneficence the introduction of these agencies,
a short half century’s contribution toward the
solution of problems of human suffering
hitherto regarded as eternal and insoluble.”
We have ceased to wonder because of the daily
application of the principles we have learned
and the marvelous results being accomplished
in medicine and surgery, yet I may remind you
that Dr. Keen, of Philadelphia, who, happily,
is still alive, records that he heard the first
obstetrician of bis day say that “any man who
opened the abdomen to remove an ovarian
tumor should be indicted for murder”, and
but a few years ago the same distinguished
author said that the abdomen, which was
formerly forbidden ground, might almost be
called a play-ground in which surgeons dis-
port themselves to their hearts’ content ; al-
ways, however, in the perfection of some new
technic or the performance of some needed
operation. He tells us, too, that when he be-
gan the study of medicine, about the same
time as Dr. Sproul, whom you honored this
morning, there were no laboratories of physi-
ology, of histology, nor pathology, nor any
instruction given in diseases of the eye, ear,
nose or throat, orthopedics, diseases of chil-
dren or gynecology. Very remarkable, indeed,
are the advances that have been made in the
last generation or so, and it would be hearten-
ing and profitable had we the time to dwell
upon these accomplishments, but it will al-
ways be the glory of the nineteenth century
that medicine was then placed on a rational,
scientific basis, affording scientific methods of
study which will ultimately lead to the unravel-
ling of the mysteries of all infectious diseases
and their conquest, and which will redound to
the credit of medicine as a blessed and altruistic
calling.
I had the great pleasure of attending the
last session of the American Medical Associa-
112
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1921
tion as a Delegate from our State Society. It
is a great privilege and honor to participate in
the transactions of that splendid body of physi-
cians representing all parts of our great country
and see how earnest and zealous they are in
their efforts to elevate the standards of medicine
and medical men, and thus help the people
whom they worthily represent. It is very in-
spiring to witness the business-like way these
sincerely interested men deal with the many
perplexing problems that arise and always with
the thought in mind of justice to the rank and
tile of the profession. Many important ques-
tions of public policy, affecting the profession,
hospitals and the laity were considered and
judiciously disposed of. The Veterans’ Hos-
pital Bill and the Veterans’ Pension Act, both
of which were regarded by the majority as
unwise and iniquitous legislation, were unani-
mously disapproved, such action being tele-
graphed to President Hoover, who referred in
his veto message to having been influenced by
the House of Delegates. But perhaps the most
forward looking suggestion of some time, and
which will have a profound influence upon the
relations of physicians to the sick poor and
the conduct of hospitals, came from the pen
of William Gary Morgan in his inaugural ad-
dress. In brief, this was to the effect that the
expense of caring for the sick poor in every
community should be borne by all the people
of that community, and should be met by di-
rect taxation ; that the physician was no more
responsible for, nor bound to relieve, the illness
or misfortune that might come upon his neigh-
bor than any other citizen ; that in all semi-
public hospitals the laboratories and operating
rooms were to be kept up to the highest point
of efficiency but that all use of such labora-
tories by the well-to-do, or all services rendered
to such people by members of the staff, was
to be paid for, and paid to the physicians ren-
dering such service; and. further, that in all
purely public hospitals no charges for services
should be made, and physicians or surgeons
would have no right to serve if charges for
service were made and retained by the city.
While such propositions might seem revolution-
ary and contrary to the long established tra-
ditions of the medical profession, a little con-
sideration and reflection upon the many in-
justices perpetrated upon medical men will con-
vince one of their fairness and justice. A
hopelessly ill person, or an acutely ill person,
without means is a charge upon his or her
community and not solely upon Dr. Smith or
Dr. Jones. If medical men choose to give their
time and services, as they always have and
will, to the purely public hospital, the city must j
see that proper provision is made for rendering
such care as is necessary, but that only those I
who are totally unable to pay shall be admitted, I
and that no attempt be made to help pay the ex- 1
pense for conducting such hospitals by charg- 1
ing for services of the members of the staff. I
In short this address proposes to distribute the 1
burden of medical care and surgical skill of a
the sick poor upon the whole community in- I
stead of upon the physicians and surgeons, I
and to prevent the abuses, prevalent in all I
cities, of the fairly well-to-do profiting by the I
appointments and laboratories of the semi-B
public and public hospitals and of the time I
and services of the attending staff.
Consideration of this subject brings us nat- I
urally to another, very much in the public eye I
— the high cost of medical care — concerning I
which I may repeat what has often been said, I
that increased fees of physicians and surgeons ]
are not alone responsible for the present agi-B
tation. My own impression is that extravagant
habits of thought and living on the part of
nearly everybody have contributed most to the I
present cost of illness. The era of prosperity I
immediately following the World War, with j
the unprecedented rise in wages of the laborer I
and the ability to purchase, too often on the 1
installment plan, comforts and conveniences I
formerly possessed only by the well-to-do, has I
engendered in everybody habits of living up 1
to and well beyond their justifiable needs. And, i
just as everybody today possesses automobiles. 1
radios, frigidaires, and the like, so everybody I
when ill must go to the hospital, and only the 1
very poor will not insist upon having a private I
room with special care day and night. Natur- 1
ally enough, hospitals have increased in num-
ber, in elaborateness of construction and ap-
pointments, until many of them are little less I
palatial than the finest hotels. Every possible ]
improvement in laboratory equipment and
therapeutic appliances must be installed and.
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
113
rightly so, the executive, clerical, nursing, in-
tern and culinary forces have to be enlarged,
with resulting rise in overhead expenses, and
so the cost has mounted until it has become a
matter of investigation and, even, reproach.
Perhaps no one concerned is entirely free
from some responsibility in the matter, but I
still feel that hospitals, for the successful ful-
fillment of their work, need only be well con-
structed, fire-proof, providing light and air,
and clean rooms with capable nursing force,
and the very best possible provision for good
surgical work and medical investigations. This
does not include rooms en suite nor suites for
relatives and friends, nor even rooms with
baths, which bath rooms arc very rarely used
by the patient and are too often receptacles for
soiled clothing. Nor is it necessary for every-
body when ill to go to hospitals. Many such
people can be properly cared for at home, and
minor surgical operations properly performed
there.
Greater judgment should be exercised in ad-
vising x-ray and other laboratory examinations
and the routine, repeated blood and other ex-
aminations are expensive and very often un-
necessary. Not every abdominal pain calls for
a G. I. series, nor every slight injury to head
or limbs for x-ray pictures to determine the
presence of fractures. Greater caution, too.
should be taken in advising surgical procedures.
Not every joint pain calls for removal of teeth
or tonsils, and not every abdominal pain spells
chronic appendicitis or diseased tubes. The
truth is that the art of history taking, physical
examination and diagnosis is being neglected
and too frequent resort is made to laboratory
and other aids which add materially to the cost
of illness. Too many procedures are advo-
cated, which often are of no avail. Trans-
fusions, for instance, will replace blood that
has been lost and supply needed elements to
prevent further bleeding, and are wonderfully
helpful and life saving procedures, but they
will not cure septicemia nor pernicious anemia,
nor septic peritonitis, and failure of any one
method often brings other methods into disre-
pute. X-rays and radium are, at times, valu-
able aids in treatment but will not cure large
uterine fibroids, nor cystic or colloid goiter ;
much less will violet ray or other lights, which
are rarely helpful. Indeed, while there may be
a modicum of good in light therapy and physio-
therapy, their indiscriminate use is not only
needlessly expensive but often results in the
loss of good chance of recovery by other
methods.
The nursing problem has become an acute
one. We are well aware that the hours of duty
are being shortened while the wages have in-
creased, and often the presence of a large
number of private nurses has, in my experience,
lessened the inclination to work by the ward
nurses, and many patients are compelled to
employ special nurses in order to receive proper
care.
The matter of fees is one upon which it is
quite impossible to draw any hard and fast
lines. In general, charges should be based upon
the character of the illness or surgical operation
and the position, civic or otherwise, of the pa-
tient ; in other words, in proportion to the re-
sponsibility and the skill involved. It is my im-
pression that excessive fees are charged by
some specialists for operations where there is
no great risk or skill required.
But, after all, in discussing the high cost
of medical care, let us not forget that many
people boast of the number of operations they
have had and of the fees they have paid. Many
people seem to prefer the services of high
priced specialists, partly, at least, for the pleas-
ure of boasting about it; others, having only
minor operations insist upon having nice rooms,
which are kept filled with choice flowers, and
which they gladly pay for because of the im-
pression made upon visiting relatives and
friends, and not infrequently at the expense of
the physican when the question of payment is
raised. All of which bears out my contention
that extravagance has much to do with the
cost of medical care.
Please do not think that I am indicting the
specialist or reflecting upon the general prac-
titioner or surgeon, but there are practices
which have crept into our methods which have
a material influence upon the question at issue
and which are often overlooked by those con-
sidering the subject.
1 1 4
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
THE COUNTY SOCIETY*
S. Emlen Stokes, M.D.,
Moorestown, N. J.
When informed that I was supposed to give
the annual address to this group, our secre-
tary told me that the last 3 Presidents had writ-
ten on the history of medicine in Burlington
County and he thought it advisable for me to
change the subject to something like “Golf as
a Hobby for Doctors”. I must say that this
was a good suggestion for I should have felt
much more at ease in talking on that sub-
ject, but once in a while my mind does strike
upon more serious topics and, in thinking over
what might be appropriate to say today, my
thoughts have continually come back to one idea
and that is : What does our County Medical So-
ciety mean to its members? Is it an organiza-
tion which lends its weight to the advancement
of our profession? Are our meetings a place
where we obtain helpful advice, not only from
the papers read but from social contact with
our fellow physicians? Are we working in har-
mony, as a society, for improvement of the
medical care of the citizens of Burlington
County? Many other such questions have been
passing through my mind.
Please do not censure me too much if what
I have to say does not agree with some of your
thoughts or if some of my conclusions are
wrong, but I do have a concern that our society
shall keep in step with medical progress and
that Burlington County may be recognized as
a place where young medical men may come
for general practice, and even for the special-
ties, knowing they will find in our group men
of the highest caliber and who will not let
petty jealousies and criticisms obstruct good
work.
It has always been said that medical men are
poor business men. In one sense of the word,
I believe that is a compliment. The business
world is a world of competition, of cutting
prices, of under-selling and under-bidding, of
patenting new discoveries, of criticizing com-
petitors’ products, and so on. Fortunately, all
‘(Presidential Address to the Burlington County
Medical Society, Nov. 12, 1930.)
of these practices are frowned upon by the
medical profession. They are discouraged and
stamped out to a large extent but I see many
signs which tell me there are still some who
do not abide by the Code of Ethics of our so-
ciety. There are men in our county who
severely criticize, to their patients, the work
of a fellow physician. Will it not leave a much
better impression with the patient if the physi-
cian in charge says nothing about the previous
care a patient has had, but rather lays par- 1
ticular stress on careful history, physical ex-
amination and treatment? I cannot help feel-
ing that this type of friction has driven many
of our citizens to cultists and to quack cures. ]
I hey get tired of hearing one thing from one
physician and something different from an- I
other. The public is rapidly becoming medi-
cally wise, and in order that we hold its re-
spect we must keep abreast of the times and
cease petty insinuations and criticisms.
I should like to digress here just a moment
and mention a subject which has made me feel
that possibly the members of our society are
not assuming proper leadership in the matter
of preventive medicine. For the past 2 '
years our state society, through its county so-
cieties, has been putting on a Campaign of
Diphtheria Immunization. It seems to me that
this can best be accomplished by every physi-
cian in our county inquiring about and making
a record of every child that comes to his office,
as to whether this immunization has been car-
ried out and, if it has not been done, to strongly j
advise it. The same is true of vaccination. There j
are entirely too many children of school age
in our county who have never been vaccinated,
and each one should be considered a menace.
It was the custom, 30 years ago, for each pliysi- ]
cian to automatically vaccinate every child un-
der his care when 4 to 6 months of age, and
the vaccination was almost included in the
obstetric fee. I am convinced that the present
laxness is largely due to us, as physicians; we
have not brought it to the attention of the
parents, and they naturally have overlooked it.
It would not be necessary to put on campaigns
if we individually assumed the responsibility
which is ours and ours alone.
T have already mentioned that some business '
practices are frowned upon bv the medical pro-
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JI RSEY
115
fession and justly so, I believe, but there are
factors in a doctors life which should be
strictly on a business basis. These factors have
to do with the commercial aspect of our profes-
sion, namely, fees, collection of bills, etc. Much
has been written lately on the increasing cost
of medical care. The American Medical As-
sociation is now engaged in collecting figures
on the cost of such care and by so compiling
statistics to be able to draw some definite con-
clusions. There is an excellent article in the
Journal A. M. A. of March 29, 1930, dealing
with the cost of medical care from the point
of view of the general practitioner. The fac-
tors discussed are: (1) The traditional opposi-
tion to discussion of the so-called commercial
aspects of medical practice. Dr. Holdbrook
here points out that as a rule our patients seek
medical and surgical advice without any definite
understanding of the obligation incurred. Tra-
dition has taught the patient that he is not
expected to approach the physician as to cost
of his services. He feels that the only ra-
tional solution of this difficulty is to break
away from illogical traditions and establish
franker business relations with our patients.
(2) The traditional custom of charging fixed
fees. Here Dr. Holdbrook makes a plea for
individualizing charges with particular con-
sideration of 3 factors — the physician’s quali-
fications, the patient’s ability to pay, and the
service rendered. (3) Inconsiderate hospital-
ization. (4) Unnecessary consultation of
specialists. In my mind, there is no doubt but
that the general practitioner is still the essential
force in the profession. With him should rest
the decision as to whether patients shou’d be
hospitalized or should consult specialists. These
decisions mean much more to the patient than
we realize and we should not be too hasty in
our advice.
In speaking of hospitalization I want to
mention a force that has entered our medical
life during the past 2 years, which I feel is as
big an influence in establishing harmony of
thought and purpose in our society as any-
thing we could hope for, and that is our County
Hospital. Those men who are giving their
time to this institution, which was so heartily en-
dorsed by our society, are reaping untold bene-
fits and pleasure from their work; they are on
a much more friendly basis with their asso
ciates, they are able to see the type of work
that is being done in the county, and, above
all, are exhibiting a type of work which we
should all be proud of. The laymen of our
county are also appreciative of the advantages
of this hospital and are more than pleased with
the treatment received. I wish I could prevail
upon those of our county society who either
are not on the staff or who have not sent pa-
tients To the hospital that they make an effort
to learn more about the work that is going on
in this institution, for it is a real privilege to
have this hospital so close at hand.
Our membership is 54 and our average at-
tendance at the county meetings for the past 2
years has been 18 to 20. This is not a good
record and indicates either that our programs
are not sufficiently attractive to call out our
members or else that our members have lost
interest in organizing and working together.
Organizatioh and professional contacts are im-
portant ; therefore, let us show more activity
as a group.
This has been somewhat of a rambling paper
but has been stimulated by an honest desire to
see our society grow.
In conclusion, I would sum up by saying :
Let us attend our county meetings with more
regularity. Let us bring to our meetings topics
for helpful and interesting discussion. Let us
work in harmony and forget petty disagree-
ments. Finally, let us give to our patients more
time and thoughtful advice.
MEDICAL SERVICE OF THE FUTURE
G. W. Haigh, M.D.,
Worcester, Mass.
In spite of the marvelous growth of the
medical sciences and the abundance of well
trained doctors, preventable and curable dis-
eases cause an appalling proportion of the pre-
vailing mortality. According to Dr. H. L.
Willett, Jr., Assistant Director of the Gorgas
Institute, they account for 61% of the total
deaths. The corresponding amount of un-
necessary sickness must be tremendous. The
conditions surely present a momentous prob-
lem challenging all classes entrusted with the
1 1 G
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
welfare of mankind. They testify to the gross
deficiency of the prevailing competitive form
of medical practice, a heritage from primitive
ages.
This astounding inability of man to derive
commensurate benefits from modern medicine
lies in the need of the proper organization of
the separate health agencies. As no less an
authority than Dr. Ray L. Wilbur, Secretary
of the Interior, has repeatedly declared-, it is
a matter of universally distributing the facili-
ties for the best possible medical care. For this,
the only practical method has been found to
be a free service. In its incomplete form it
has been developed in the out-patient depart-
ments and the wards of hospitals, and in indus-
trial and health clinics. In its complete form
it has functioned notably in our navy and
army. To our president and our representa-
tives in Washington is furnished this very
medical service.
That free, universal medicine is no new or
fanciful idea is shown by an editorial upon
“Free Health” in the “Survey” of May 13,
1911, nearly a score of years ago. It is quoted
in part, here:
“Free education was once considered radi-
cal, but it was followed by compulsory educa-
tion, and with compulsory education illiteracy
became extinct among the native born. This
free, compulsory education was neither char-
ity nor justice, though free schools began as
charity. It was protection, for revenue only,
for society saw that ignorance was costly and
dangerous.
Free health is now radical, but it will come
and compulsory health will follow. No child is
now allowed to be ignorant, whether its par-
ents are willing or unwilling; but disease is
both more contagious and more dangerous than
ignorance. Conversely, health is more precious
than knowledge, both to the individual and to
the community. The tenement father who sees
his boy go through grammar school and die of
tuberculosis would rather have a live son than
a wise one. The wages of unskilled labor in
the tenements do not allow health but educa-
tion is given free. Which would any father
choose for his child? Which should humanity,
or policy, first give? Public health is quite as
important to the community as public educa-
tion, and we shall some time have free doc
tors as well as free teachers, leaving the private
doctors, like the private schools, for the few
who can afiford and prefer them.
There are signs of this in the increasing
number of doctors already in official service in
our health departments and elsewhere. Twenty
years ago we had city hospitals and city poor
physicians. Now the public roster shows
tuberculosis inspectors, tenement inspectors,
food, milk, and drug inspectors, school medical
inspectors, school nurses, bacteriologists, and
even school dentists ; and we might add as
health officials the smoke inspectors, public
bath house keepers, and the playground direc-
tors. Many cities pay for public lectures on
sanitation, hygiene, feeding, and flies. The
social value of public health is incalculable, and
the public is realizing this.”
These thoughts penned almost 20 years ago
are not only true but singularly timely.
In most countries of Western Europe var-
ious systems of gratuitous medical service have
been in operation for some time. Not one of
them, however, as was observed by Dr. Wins-
low, Professor of Public Health at Yale, in his
tour of investigation as member of a com-
mission of the League of Nations, is com-
patible with our institutions and traditions, be-
cause they savor too much of class legislation.
1 hey represent diverse insurance schemes, de-
signed primarily for the poor. They resemble
somewhat the cheap contract service rendered
fraternal societies in many of our larger com-
munities. Because of being incompletely or-
ganized, they retain the evils of individualistic,
competitive practice and lack the advantages
of cooperative medicine.
In an article published in the American Mag-
azine of April 1916, entitled, “Better Doctor-
ing for Less Money”, Dr. Richard Cabot, in-
ternationally renowned in the realms of both
medicine and sociology, showed the impossi-
bility of the majority of the people obtaining
the full blessings of scientific medicine so long
as they depended upon the single practitioner.
He explained that there were 2 reasons for
this: first, the need of close cooperation and
team work ; and second, the prohibitive cost of
competition of unorganized individual special-
Feb.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
117
ists whose skill has become more and more in-
dispensable.
In 1916, also, there was held at Washington
a conference on social insurance called by the
international association of Industrial Accident
Boards and Commissions. So important were
its proceedings that they were published in full
by the Bureau of Labor Statistics of the
United States Department of Labor, in Bul-
letin 212. About one-third of the sessions were
devoted to the subject of sickness benefits and
insurance. The speakers included represen-
tatives of employees as well as employers of
insurance companies and societies, government
and private health and welfare agencies, *besides
private and public health doctors of medicine.
They were almost unanimously agreed that
health insurance was needed. They favored an
organization corresponding to the British Panel
System in which the privilege of selecting one’s
physician from among competitive individuals
is permitted and in which are introduced in-
termediary agents or referees of the insurance
companies or the friendly societies to super-
vise the work of the physicians, because the
doctors, though paid by the insurers for services
rendered to the insured, are tempted to be
too partial to their patients, whose good will
they naturally strive to keep. This particular
system, which had not then been thoroughly
tested, has since proved to be incompatible with
scientific medicine. It will probably be super-
seded by a free public service.
During the World War fully organized
medicine maintained the health and fitness of
the naval and military personnel at such a
level that for the first time more combatants
were killed by projectiles than by diseases.
Surely the sudden and vast recruiting of the
regular medical corps of both the navy and
the army subjected such a health system to
a most severe and thorough test. Since their
members, most of whom were enrolled tem-
porarily for the duration of the war and had
been unaccustomed to discipline and coopera-
tion, did cope so successfully with the prob-
lems of mobile forces exposed to the greatest
hazards to health and vigor, certainly such an
organization would insure the adequacy and
efficiency of a permanent body with its in-
herent esprit de corps, ministering to the rela-
tively immobile civilian population.
Since the war the necessity for such a free
health service has become imperative. The
medical sciences have been growing so fast as
to increase the demand for genuine specializa-
tion. But many specialists, self-appointed,
have not complied with any recognized stand-
ard. They have pursued their profession in-
dependently and unrestrainedly. They have un-
duly encroached upon the province of the gen-
eral practitioner, disrupting his practice and
increasing the expensiveness of medical diag-
nosis and treatment more than ever. For, in
general, the division of labor without organiza-
tipn is bound to add to the cost of its product
and, besides, because of waste and friction,
competition in a public necessity cannot fail
to do likewise. So these unbridled members
of the profession require control and regula-
tion by incorporating them with physicians, in
general, into a service like that of the navy.
Since the war, furthermore, private and pub-
lic health agencies have so multiplied and ex-
panded as to decrease materially the available
profitable work for private physicians. More-
over, with the decline of the prestige of reg-
ular doctors struggling for a: livelihood, multi-
farious healers have invaded the field of medi-
cine. For these reasons specialists, particu-
larly upon whom falls the burden of most
charity seiwice in hospitals, have been com-
pelled to demand of theii paying patients ex-
cessive fees. Some have adopted the business
principle of charging all that the traffic will
bear. They were abetted by the recent period
of unprecedented prosperity. Its collapse,
however, and the return of a normal or sub-
normal economic State will accentuate the urg-
ency of cooperative public medicine.
So, it is but natural that the present chaotic
status of medicine should give rise to much dis-
satisfaction. The poor, who are dependent
upon hospital service, suffer from want of
home treatment. The rich complain about the
extortionate fees of the experts, whose time
and energy are partly consumed by charity pa-
tients. Middle class patients, blindly groping
for succor, are embarrassed most of all by the
prevailing disorder and confusion because they
are paying dearly for the poorest treatment.
118
JOURNAL OK THE MEDICAL SOCIETY OK NEW JERSEY
Feb., 1931
Among doctors, too, the conditions of prac-
tice today are unsatisfactory. The medical man
begrudges the surgeon his large fees, especially
since many are derived from operations such
as he himself performed while serving as an
intern. He is vexed by the anomalous state of
a profession in which hand work pays much
better than brain work. The honest scientific
doctor is disgusted or worried by a widening
divergence between the intelligent pursuit and
the actual practice of his profession. He re-
sents the success of the dishonest practitioner
who lures gregarious mankind by his sheer
artfulness and his ostentatious appurtenances;
not from envy of him but from sorrow for the
beguiled and the benighted, denied the advan-
tages of scientific medicine. In this day of
quick transportation and instantaneous com-
munication the conscientious physician depre-
cates the fact that the practice of medicine con-
tinues to lag so far behind the theory of medi-
cine. Why should it have taken at least 15
years to educate the practicing physicians in
the correct use of diphtheria antitoxin, one of
the few specific internal remedies? Also, why
should the mortality from appendicitis have
actually increased during the last 5 years?
The flagrant inadequacy of medicine has been
fearlessly decried by a few leading medical
men. They have piqued many of their fellows,
smug and complacent, who like rabid members
of trade unions have forgotten that every part
of society exists for the good of the whole, not
the whole for any one part. Dr. William Mayo,
one of the founders of the far-famed Mayo/
Clinic, publicly declared that there were in cer-
tain aspects of medicine too much salesmanship
and too little humanity. He stated what Dr.
Cabot implied in his article, to which refer-
ence has already been made, that the ward pa-
tient under the care of the regular hospital
staff usually received better treatment than
the private room patient attended by his in-
dividually selected doctor.
In the issue of Harper’s Magazine for Sep-
tember 1929, Dr. Joseph Collins in his contribu-
tion, “The Patient’s Dilemma”, showed that
nowadays patients had to do considerable shop-
ping among doctors before they could obtain
personal satisfaction. He asserted that the
root of the evils of medicine today lay in
money. It is true that the vital perplexing
questions he raised can be answered only by
the deliberate institution of a free, ready
medical service.
Since, after all, the subject of proper medical
care is sociologic, laymen have quite naturally
undertaken to solve this baffling problem, than
which there is not one more important. Soci-
ologists have rightfully denounced medical prac-
tices. Their studies and opinions, however,
have not been widely diffused. The first busi-
ness man openly to find fault with medicine’s
unreasonable status was Edwin A. Filene, the
Boston merchant. To. the January 1930 Gra-
phic Survey he contributed an essay in which
he condemned the inefficiency and waste of un-
organized medicine, into which he has gained a
clean insight through his personal relations
with numerous employees about whose happi-
ness he has been much concerned. .He advo-
cated the injection into medicine of business
methods such as have made possible so many
beneficent industrial and philanthropic organ-
izations of this progressive era. Without
business profits, however, nothing can intro-
duce into medical practice such efficiency and
humanity as a free system patterned upon that
of the United States Navy.
Is it not evident, therefore, that at this stage
in our civilization a system of free public medi-
cine is urgently needed? In civilian life prog-
ress in medical economics has obviously lagged
far behind the advancement of medical science.
In the navy, however, it is not so. As soon as
the people are aware of this fact, like represen-
tatives in Washington, they will adopt such a
service as the Bureau of Medicine and Sur-
gery of the Navy, whose function is to pre-
serve the fitness of each of the personnel for
his duties and to restore any of them to duty
as promptly and as fully as possible. This
means the practice of preventive medicine
primarily and of curative medicine secondarily :
without question a sensible purpose. With this,
contrast civilian practice, in which, on the one
hand, the patient procrastinates in seeking re-
lief from his affliction and, on the other, the
physician seems too busy prescribing for ail-
ments to take much interest in keeping people
well. As a matter of fact he is rarely hired
to do so. So long as the civilian doctor is paid
F'eb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
1 1 9
by the visits he makes instead of by the time
that he spends, he will be tempted to neglect
the most important phases of medicine, namely
personal hygiene and public health.
How does the medical corps serve the naval
personnel? Every applicant for the navy is,
of course, thoroughly examined by one or
more medical officers. Every member is re-
examined on frequent occasions, whenever he
is promoted or transferred, as well as when
ill or injured. All officers undergo at least
one regular physical examination every year.
So, every one must be found physically fit for
his specific duties, whatever they may be or
whenever they may change. Every member
must be protected against infection with any
communicable disease in which appropriate
vaccination is effective. Whenever anybody
appears to be unable to perform all his duties
on account of illness or injury, he is immediately
referred to the medical officer on duty. The
medical officer must ascertain, if possible, the
cause of the complaint and decide what should
be done for the patient. If the patient be dis-
abled, he is kept under the care of the medical
department and his name is posted upon the
sick list until he has been pronounced fit to
return to duty. Possibly he requires admis-
sion to the hospital, where he receives intensive
study and appropriate treatment.
The naval surgeon, moreover, takes a nat-
ural interest in everything in the environment
of the personnel that may affect health. He
is responsible for sanitation of the ship or
the shore station to which he is officially at-
tached ; in particular, the clothing, food, quar-
ters, working conditions, and athletics; in gen-
eral, everything which may impair health,
jeopardize life, or endanger limbs. He instructs
members of the crew in first aid and in hygiene.
He is a true teacher quite worthy of his title of
doctor.
The assignments of naval surgeons depend
much upon their rank, which is determined
chiefly by their knowledge, skill and exper-
ience. The younger men are attached to smaller
vessels or stations in charge of all medical
matters or to hospitals or larger stations as
assistants to their superiors. The older sur-
geons fill administrative positions as command-
ing or executive officers in hospitals, in the
offices of the central bureau at Washington, or
in the Naval Medical College. Those in the in-
termediate ranks are usually engaged in active
medical and surgical practice. They are en-
couraged to become expert in at least one
specialty of medicine. In contrast to the
civilian doctor who renders whatever menial
personal service his patients demand, the
naval surgeon as he rises in rank is en-
trusted with greater responsibilities and ac-
cordingly relieved of the simpler routine
duties which are carried out with more zest
by his juniors. He aids those below him, he
is aided by those above him, ever ready to co-
operate. He is able to practice his profession
intelligently, because he has no occasion to
bluff or to guess. He does not need to hurry ;
he must do his work with diligence and pre-
cision, since he is supervised and checked both
directly by those associated with him, and in-
directly by those at the headquarters of the
Bureau of Medicine and Surgery. If his effi-
ciency be impaired by sickness or fatigue, he
is temporarily relieved of duty. Since, as he
attains the higher ranks, the scope for his
energies increases he is happy to pursue his
profession for its intrinsic gratifications, where-
as the civilian physician aspires to attain a
competence so as to escape from the servitude
of his patients or to relinquish the private prac-
tice of medicine entirely for something more
congenial and less arduous, like business or
banking or politics. To medicine alone the
naval doctor dedicates his whole career and
gives to his fellow men the full benefit of his
mature judgment.
The naval doctors are stimulated to main-
tain a high standard by means of constant
affiliation with their colleagues in 2 ways :
through rivalry with those of equal rank and
through supervision and control by those of
superior rank. That they do maintain a qual-
ity of practice above that of civilian physicians
is attested to by many civilians serving with
them during the World War. That fact is
tacitly acknowledged, furthermore, by the
American Medical Association, which admits
all naval medical officers to fellowship uncon-
ditionally, automatically by virtue of their
commissions, whereas fewer than half the
civilian physicians can meet the necessary pro-
120
HH RNAL 01 THE MEDICAL SOCIETY OF NEW JERSEY
fessional qualifications for admission to fellow-
ship. Finally, Congress has thought well
enough of the medical corps of the Navy and
Army to vote its members the right to free
service. Surely at a time when congressional
fact-finding and fault-finding committees or
commissions are investigating almost every-
thing there is no need of additional evidence
of the superiority of such a medical service
over competitive practice.
Such an organization as the Bureau of Medi-
cine and Surgery of the Navy can be applied
to civilian practice either by expanding the
present public health department of any com-
monwealth or by creating a bureau of public
medicine incorporating that department, the
welfare department, industrial accident board,
municipal and county hospitals, and what-
evei private hospitals may be required to
furnish a state-wide service. It would con-
stitute a complete public system of medicine
with free professional service for all estab-
lished residents of the state. It would be
composed of full time medical officers of dif-
ferent ranks, according to their respective abil-
ity and experience, working together in and
about hospital bases with the necessary aux-
iliary personnel, so well organized as to in-
sure suitable discipline, supervision, and con-
trol of each member, and to stimulate interest
and effort by rewards of promotion and prizes.
1 he hospital units would be coordinated by a
central state bureau with the requisite admin-
istrative divisions. One of the most valuable
functions of such a medical corps would be the
keeping of permanent health records of each
patient, in fact of every citizen, to facilitate and
expedite the successful management especially
of urgent cases. Whereas in the present cha-
otic state of private competitive practice many
people often do not know where to obtain
proper medical attention or cannot afford it;
government medicine, furthermore, would not
only furnish the best possible service, but would
also readily guide the patient, though suffering
and bewildered, to the source of optimum treat-
ment.
Under this proposed complete system of co-
operative medicine, since the individual physi-
cian would necessarily be subservient to the
whole, a patient’s choice of doctor would be
absolutely precluded. And so it has been for
dt cades for those ward patients who have avail-
ed themselves of the superior service offered by
tht larger well organized hospitals where the
best scientific medicine has been practiced. And
so it must be from the very nature of modern
medicine, founded upon the rapidly growing
and expanding sciences for which team work is
die sine qua non. Today this freedom to select
one’s physician actually redounds to the dis-
advantage of the patient, who does not know
where to procure the best advice, because of
the obsolescence of the genuine family doctor,
ever ready to serve the child or the grown-up'
day or night, and the absence of any successor
to aid or to guide. On account of the gre-
gai iousness of mankind, this selective privi-
lege has been responsible, according to esti-
mates of drug salesmen calling upon physi-
cians, lot about 20% of the doctors doing
about 80% of the medical and surgical work.
I his has certainly encouraged, on the part of
the busy popular practitioners on the one hand,
haste, carelessness, and fatigue with conse-
quent inefficiency ; on the other, rank commer-
cialization of medicine and heartless exploita-
tion of patients. It has fostered the practice
ol the art, or easier phase of medicine, and
stifled the scientific or harder. It has nurtured
much bunk, humbug, and license; it has sup-
pressed much honesty and truth.
Since, finally, the welfare of the people is
a primary function of a democracy, only the
government can supply a universal need which,
h is generally admitted, private agencies have
signally failed to meet. This utility is undeni-
ably of prime importance to every one, young
and old, unborn as well as born. For health
has now become more essential to success and
happiness than education. Public education
has long ceased to be socialistic. So, surely,
public or state medicine cannot be rejected as
undemocratic. Moreover, no longer to be re-
garded as untenable is the application to their
own purposes of such an excellent medical or-
ganization as that of the Medical Corps of the
United States Navy.
Jn conclusion are quoted 4 pertinent sen-
tences from the inaugural address of President
Hoover.
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
121
“In public health the advances of science
have opened a new era.”
“Many sections of our country and many
groups of our citizens are suffering from dis-
eases the eradication of which are mere mat-
ters of administration and moderate expendi-
ture.”
“Public health service should be as fully or-
ganized and as universally incorporated into
our government system as is public education.”
“The returns are a thousand fold in eco-
nomic benefits, ■ and infinitely more in the re-
duction of suffering and the promotion of
human happiness.”
SOME SOURCES OF INFORMATION
AND MISINFORMATION IN
CARDIAC DIAGNOSIS'
Jacob Polevski, M.D.,
Newark, N. J.
The clinician of today depends a great deal
for his diagnosis on the so-called modern
methods of precision that the laboratory offers,
one of the most important of which is roent-
genology in the study of cardiac conditions. A
greater accuracy in diagnosis, is the concern
of the present contribution.
The amount of information the clinician de-
rives from a roentgenologic plate or series of
plates in the study of a gastro-enterologic or
pulmonary condition is invaluable. The find-
ings are fairly positive and sources of error
are rather negligible. Not so with roent-
genologic plates of the heart. The possibility
of distortion of shape and configuration of the
heart shadow on the film by improper position
of the patient in relation to the tube is obvious.
The attempt to obtain the actual size of the
Fig'. 1. Short stocky patient with a high diaphragm.
Heart shadow is of a distinctly aortic type;
cardiac angle very pronounced,
aortic knob prominent.
cardiac roentgenogram taken at a distance of
6 feet is supposed to offer the clinician a tre-
mendous amount of information regarding the
actual size and the normalcy or abnormality of
configuration of the heart as a whole or of its
various parts. How much this laboratory aid,
as generally carried out, helps to inform or
misinform the clinician in his search for
*(From the Department of Cardiology of the
Newark Beth Israel Hospital.)
heart by the plate at 6 feet distance, or by ortho-
diagraphic tracing under the fluoroscope, is not
always rewarded with an accurate result, as we
shall point out subsequently. There are var-
ious factors that influence and frequently vitiate
the result.
It is not within the scope of this contribu-
tion to go into minute descriptions of all the
possible errors, shortcomings, and methods of
their correction, in the roentgenologic study of
122
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., I9:u
the heart; we shall limit ourselves to a few
phases of the subject, its difficulties, sources of
error and methods of overcoming them.
When one attempts to familiarize himself
with an object whose surfaces are rather of a
complicated nature, he will look at it from
every side and angle. 'A picture of one sur-
face will by no means suffice to give a com-
prehensive idea to the shape and configuration
of the object, and yet, this is precisely the situ-
ation with roentgenology of the heart or of its
various parts when we attempt to draw a con-
clusion from study of one film only. The fal-
lacy of this method is obvious. The heart occu-
thus varies with the respiratory phase of the
diaphragm and lung movements. It is also in-
fluenced by many other extrinsic factors, as we
shall point out presently. When the diaphragm
descends during inspiration the heart not only
assumes a more vertical direction but also
changes from a somewhat levo to a more mesial
position. While doing this, the heart also per-
forms a rotary motion, thus bringing various
parts of the heart that are usually seen en face,
into a more profile position. Furthermore, on
inspiration, the expanded lungs exert a great
deal of pressure upon the surrounded heart and
bring about an appreciable diminution in its
Fig:. 2. Same case as in Fig-. 1 in deep inspiration, dia-
phragm on descending carries heart with it;
cardiac angle markedly diminished;
aortic knob less prominent.
pies the greater part of the mediastinum. It
is fixed chiefly at its upper part to the tissues
covering the spinal column by the large ves-
sels. The major or lower part of the heart is
suspended from above and is practically freely
movable. Below, it rests on the more central
part of the diaphragm, which structure under-
goes upward and downward excursions during
the 2 respiratory phases. On either side, it is
surrounded by the lungs. The position and
condition of the surrounding structures neces-
sarily greatly influence the shape and apparent
size of the heart. The position of the heart in
the mediastinum, as well as its configuration.
transverse diameter. This is particularly true
in the case of a thin-walled heart of dilatation.
1 he aortic shadow, its size and width, as
well as its intensity, play a great role in car-
diac diagnosis. Here, too, there is much to be
desired in greater accuracy of interpretation of
the shadow produced on the film or on the
screen. The usual report of the roentgen-
ologist reads as follows : The aortic arch is
widened, or the aortic knob is prominent or
accentuated. Now, as in the case of the heart
proper, the size and shape of the aorta, too,
will vary not only with intrinsic changes with-
in the aorta, but with numerous alterations in
Feb.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
123
position of the surrounding structures, parti-
cularly by the condition of the spinal column.
While studying a cardiac plate, the question
whether the heart is that of a mitral or aortic
type stands out foremost. The mitral heart,
because of the enlarged left auricle and some-
what more prominent pulmonary artery, causes
a diminution in the cardiac angle — the angle
between the upper vascular part and the lower
cardiac part of the left border, which brings
about a straightening-out or even a convexity
to the left, instead of the concavity usually
found. In the aortic heart, on the other hand,
because of hypertrophy or dilation or both of
tation, brings about a straightening of the left
border, thereby causing a marked diminution
and occasionally a complete obliteration of the
cardiac angle, thus producing a typical picture
of a mitral type heart where no mitral lesion
exists. The same prevails in the case of the
tall ptotic individual whose chest is long and
diaphragm low, thus permitting a very vertical
position of the heart even without the inspira-
tory phase. (Fig. 3.) And it is particularly in
these cases where an erroneous diagnosis of a
mitral lesion is frequently made. On the other
hand, one may err by being reluctant to make
Fig. 3. Definite ptotic heart. Long and
mesially placed.
the left ventricle, the above mentioned angle
becomes exaggerated and the concavity mark-
edly increased. It is on the basis of these
changes in the contour of the left border that
the roentgenologist bases his opinion as to the
type of heart he is confronted with.
Changes in configuration of the left border
can be and are frequently brought about by ex-
traneous factors that are not given sufficient
consideration, and the interpretation is there-
fore frequently misleading. As stated above,
on inspiration, due to the descent of the
diaphragm, the heart assumes a more vertical
position. This, coupled writh the incident ro-
a diagnosis of mitral heart when bearing in
mind the fact that this status ptoticus is con-
ducive to a pseudo-mitral shape, and thus may
miss the diagnosis ; particularly apt to occur
in the case of a silent mitral stenosis.
In case of die short, stocky individual with
a short chest and with the usually high dia-
phragm, the reverse is true. The body of the
heart proper is forced by the high diaphragm
upward, while the upper shadow, made by the
large vessels, is fixed ; in this way the cardiac
angle becomes exaggerated, and an impression
of an aortic configuration is produced.
Methods of overcoming, diagnostic difficulty.
124
JOURNAI. OK THE .MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
Fig'. 4. Heart in a ptotic patient. Very suggestive of
a mitral configuration. There was a systolic
murmur over apex. No other
signs of cardiac difficulty.
Fig. 5. Same case as in Fig. 4 in lateral position.
Esophagus shadow not indented, showing no
enlargement of either left auricle
or right ventricle.
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
125
Fig. 6. A definite case of mitral stenosis with its
typical configuration.
Fig. 7. Same case as in Fig. 6 in lateral position on
ingestion of barium paste. Upper half of retro-
cardiac part of esophagus is definitely in-
dented and displaced toward spinal col-
umn by the enlarged left auricle.
126
JOURNAL OK THE MEDICAL SOCIETY OK NEW JERSEY
Feb., 1931
In the questionable aortic type, the method is
simple. Have the patient take a deep inspira-
tion. In the true aortic heart where the in-
creased cardiac angle is due to hypertrophy of
the left ventricle the particular configuration
will persist ; while in the pseudo-aortic con-
figuration produced by high diaphragm, the
heart will straighten itself out, and the cardiac
angle will diminish as soon as the diaphragm
descends. (Figs. 1 & 2.)
In the questionable mitral heart the solution
.is not so simple. Here, inspiration will not
help us. On the contrary, it exaggerates the
tion and asked to swallow a tablespoonful of
barium paste ; when a marked indentation of the
retrocardiac esophagus by the bulging left
auricle can be clearly made out. This procedure
establishes the diagnosis of a mitral lesion be-
yond any doubt, and is an invaluable aid in
cases of questionable mitral lesion where the
only positive sign is that of a systolic murmur
at the apex. These murmurs, as we all know, I
frequently puzzle clinicians as to their sig-B
nificance, and absolute diagnosis of an organic ;
functional nature is frequently impossible.!
(Fig- 7.)
Fig. 8. Case of a young boy with mitral stenosis.
The left auricle is definitely seen on the right side
of the heart shadow v/hich is more intense at
this point because of the super-imposi-
tion of the 2 chambers.
condition. So we must resort to another method.
l'he esophagus is located immediately behind
the heart in the lower part of the mediastinum.
It courses downward in an almost straight line.
(Pig. 4.) Now, in the case of a mitral lesion,
some degree of enlargement of the left auricle
takes place to the left but chiefly posteriorly,
thus encroaching upon the posterior mediasti-
num and particularly upon the retrocardiac part
of the esophagus. The patient is placed in the
right oblique, or even in the right lateral, posi-
We might add here that occasionally the en-
larged left auricle may assume such enormous
proportions as to reach over to the right border
of the heart and produce a paradoxic situa-
tion where the left auricle makes part of the
right border of the heart. The Roentgen
shadow will show 3 curves, instead of the
normal 2, making up the right border of
the heart ; the lower curve being due to the
right auricle, the middle curve due to the left
auricle and the upper curve to the ascending
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
127
aorta. Such a third curve is often mistaken
for an aneurysmal dilatation of the root of the
aorta, or for a sacculated pericardial effusion.
This mistaken diagnosis can also be obviated
by the barium ingestion in the right oblique
position where the auricular hypertrophy can
be definitely made out. Occasionally such an
enormously enlarged left auricle will produce
physical signs of a sacculated pleural effusion
in the right interscapular space. On doing a
paracentesis one will naturally aspirate blood
oblique position. The former will appear
wider as compared with the latter.
All conditions that change the anteroposterior
relation between the ascending and descending
parts of the arch will influence its apparent
width. One of those conditions is kyphosis or
scoliosis of the spinal column. In kyphosis
the greater convexity of the spine carries the
descending part of the arch to a position al-
most immediately behind the ascending part.
Such an arch, looked at en face will, naturally,
Fig. 9. Severe case of mitral stenosis. Left auricle
projects beyond the right border of the heart.
Case proved by autopsy.
and make the diagnosis of an hemorrhagic
pleural effusion. (Figs. 8, 9, 10, 11.)
As to roentgenology of the aorta, anatomi-
cally the arch runs first upward, then back-
ward and then downward, so that the ascend-
ing part of the arch is anterior to the descend-
ing part. It is easily conceivable that anything
that will bring the descending part of the arch
more anteriorly will cause a widening of the
shadow of the arch as a whole on the screen.
'1 his is made more clear when we think of the
perspective view of a flat surface, in one in-
stance looked at en face, in the next, in a more
look extremely narrow. In scoliosis the de-
scending part of the arch assumes a more lat-
eral position in relation to the ascending part,
and thus the shadow of the arch as a whole
projected on the screen or film will appear
much wider than it really is. There are many
other factors that will influence the apparent
width of the shadow of the arch. Anything
that will flatten out the rotundity of the arch
will cause its widening without bringing about
a real change in the size of the aorta. A large
substernal thyroid pressing down on the arch
will do it. Likewise a very high diaphragm,
128
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
crowding the heart up against the arch, will do
the same. Thus, we see that taking the width
of the arch shadow as seen on the film, as an
index of the real intrinsic condition of the
aorta, may be frequently quite misleading.
However, the question arises, is it the
measurement of the width of the arch that is
of diagnostic importance, or that of the cross
section, or the diameter of the lumen of the
aorta that is of greatest consequence. On care-
ful consideration one realizes that it is the
latter that is paramount.
outermost tangential point of indentation caus-
ed by the aorta, again by the aid of the ortho-
diagraph. The measurement between the 2
tangential points minus 2 mm. that represent
the thickness of the wail of the compressed in-
terposed trachea, indicates the true width of
the aortic tube, which m the normal male adult
measures 3 to 3.5 cm. This procedure is known
as the Kreuzfuchs’ method. (Fig. 12.)
After a little application and practice, it is
accomplished very easily and without appre-
ciable loss of time. The additional few min-
Fig. 10. A most severe case of mitral stenosis. The
left auricle bulges out beyond the right border of
■ the heart. ' Case was diagnosed as a sacculated
pericardial effusion, also as a possible tu-
mor. Clinically it gave all the symp-
toms of a pleural effusion.
We must then endeavor to obtain, either on
the screen or on the film, the shadow of the
lumen of the aorta looked at en face, and then
obtain its accurate measurement. This is ac-
complished in the following way : Place the
patient in the right oblique position. Under
orthodiagraphic guidance, mark the left outer-
most tangential point of the aorta. Then have
the patient swallow a tablespoonful of the bar-
ium paste. The aortic indentation of the eso-
phagus is readily visualized. Mark the right
utes thus spent are more than repaid by the
greater exactness of information thereby de-
rived.
We pointed out above the influence of the
respiratory phases of the lungs and diaphragm
on the contour of the heart. At this point we
want to emphasize the fallacy of taking heart
roentgenograms in deep inspiration — a practice
followed by practically all roentgenologists. We
ostensibly attempt to be very exact in the
measurements of the diameters of the heart.
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
129
yet we overlook the fact, as pointed out above,
that deep inspiration will compress the heart,
particularly so when the heart is dilated, and
thus diminish the transverse diameter by 1 cm.
or more. As a matter of fact the extent of in-
spiratory compression and consequent reduc-
tion of the transverse diameter of the heart can
be utilized as a means to determine whether
widening of the transverse diameter of the
heart is due to prepondering hypertrophy or
dilation. The hypertrophied heart will suffer
little compression while the dilated organ will
be materially compressed and thus will under-
Best results and most accurate information
are obtained by resorting to fluoroscopy, when
the extent of the various changes in the shape
and size of the heart viewed from different
angles in either of the respiratory phases can
be ascertained. The fluoroscope also offers us
the opportunity to scrutinize the variation in
the contractile power of the heart. The vigor
or tardiness of the ventricular contraction con-
veys a very definite impression as to the quality
of the myocardium. If a roentgenographic
film is taken, it is best done while the patient
holds his breath midway between expiration
Fig. 11. Same case as in Fig. 10. In lateral position
on ingestion of barium paste. Upper half of re-
trocardiac part of esophagus is definitely in-
dented and displaced toward spinal col-
umn by the enlarged left auricle.
go marked diminution in its transverse dia-
meter.
It is obvious that cardiac roentgenograms
must not be taken in either extreme inspiration,
for reasons mentioned above, or in extreme
expiration, as in this phase the higher position
of the diaphragm tends to produce an apparent
aortic configuration and a false impression of
widening. In the case of severe myocardial
degeneration, deep inspiration will allow length-
ening of the heart and thus frequently obliter-
ate the typical mushroom or bottle-shape of the
heart that is of great diagnostic importance.
and inspiration or, to be more explicit, with
the patient holding his breath after a slight in-
spiration. Of course, a film in deep inspiration
looks prettier, but then, all know that beauty
and accuracy do not always go together. As
a matter of fact the film is to be used merely
as a means of permanent record.
Fluoroscopy of the heart is really the job
of the cardiologist. He should attempt to
view' the heart under the fluoroscope as one
looks at an object under a glass jar. Being
most conversant with all shades and phases of
various pathologic conditions and congenital
130
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
anomalies, he is most qualified to interpret the
findings and evaluate the various deviations
from normal. Among all the methods at his
•command, the fluoroscope should occupy the
very most important place.
Summary
(1) The respiratory phases, by changing the
pulmonic volume and diaphragmatic position,
(5) Care must be exercised not to mistake
such an enlarged left auricle for an aneurysmal
dilatation of the root of the aorta, for a sac-
culated pericardial effusion, for a mediastinal
tumor or, clinically, for a pleural effusion.
(6) The measurement of the width of the
aortic arch is no criterion of the condition of
the aorta.
(7) The width of the aorta can and should
Fig. 12. Kreuzfuchs’ method of measuring the width
of the lumen of the aorta. The barium in the eso-
phagus is definitely indented by the posterior
wall of the arch. The distance between
the 2 tangential points minus 2 mm.
represents the width of the
aortic tube.
materially influence the cardiac size and con-
figuration.
(2) A low diaphragm is conducive to mitral
configuration; conversely, a high diaphragm
is conducive to aortic configuration.
(3) Indentation of the retrocardiac part of
the esophagus rendered visible by ingestion of
barium paste is an important aid in the diag-
nosis of questionable mitral conditions.
(4) The left auricle may and often does as-
sume such enormous proportions as to reach
over posteriorly to the right border of the
heart and even project beyond it.
be determined by the measurement of the di-
ameter of the aortic tube which is made pos-
sible by the Kreuzfuchs’ method.
(8) To properly and adequately visualize
the heart and aorta one must not limit himself
to the study of a film in the anteroposterior
position, but must fluoroscope the heart from
various angles in different respiratory phases ;
also, one must observe carefully the vigor or
tardiness of the cardiac contractions.
(9) The fluoroscope is an invaluable aid in
cardiac diagnosis in the hands of the exper-
ienced cardiologist.
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
111
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J.
Entered at the post office at Orange, N. J.f as second-class matter
PUBLICATION COMMITTEE
HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J.
EDITOR:
HENRY O. REIK, M.D., F.A.C.S., Vermont Apartments, Atlantic City, N. J.
Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to
receive the paper will conier a favor by notifying the Chairman ot the Publication Committee ol the tact.
NOTE. — The transaction of business will be expedited, and prompt attention secured it:
All papers, news items, reports for publication and any matters ot medical or scientific interest, are sent direct to
The Editor, Atlantic City, N. J.
All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements,
or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication
Committee, f address above), Newark, N. J.
COUNTY SOCIETY ADVERTISING
During the past year several articles have
been published, one or two in professional
journals, the others in secular magazines, urg-
ing physicians to advertise or denouncing the
medical profession because it does not adver-
tise in the daily press. Quite recently one of
the country’s prominent evening newspapers
scolded us severely for not having aided in
wider dissemination of the Coffey-Humber
cancer cure, alleging that thousands of lives
would have been saved if the profession had
joined in the advertising of that marvelous
discovery; but, by the irony of fate, that scold-
ing was published in almost exact coincidence
with publication of refutation of the Coffey-
Humber claims. What a fine spectacle the pro-
fession would have made of itself, had it, on
the basis of such slight claims, advertised abil-
ity to cure cancer.
In so far as our observation has gone,
the pressure brought to bear upon the pro-
fession by advertising agencies, and the at-
tempts to ridicule physicians for holding fast
to a code of ethics that has well served them
and their patients for hundreds of years, have
been instigated by the “business” proclivities of
those who would unscrupulously use an honor-
able profession for the base purpose of bring-
ing a few more dollars into the paper’s adver-
tising office. We have yet to see a medical ad-
vertising plan emanating from newspapers or
magazines that bears any real evidence of in-
terest in the welfare of the physician or the
public.
Some medical societies have engaged in ad-
vertising to the extent of paying for newspaper
publication space in which to provide the public
with information concerning health promotion
or sickness prevention ; educational campaigns
for the public welfare but not for personal
gain, benefit or aggrandizement. Even that
sort of advertising has not been unanimously
approved, and it remains to be demonstrated
that it is wise policy for our county societies,
or for any other units of organized medicine.
Our attention has been forcibly drawn to
this question during the past few weeks by a
proposition submitted to one of our own com-
ponent county societies. You may observe in
the reported proceedings of the Camden County
Society, in this issue, that the society “referred
to the State Society Welfare Committee a sug-
gestion from one of the local newspapers con-
cerning paid educational advertisements which
were to be run in series”. To be exact, the
proposition was referred to the Chairman of
the Welfare Committee, and by him was re-
ferred to the Executive Secretary for consider-
ation. We are publishing now our opinion be-
cause we fear the same proposition may appear
in some other county society, and deem it wise
to endeavor to prevent any group from inno-
cently falling for the scheme. The following
letter to the Secretary of the Camden County
Medical Society will explain the proposition
and our views thereon :
"January 18, 1931.
Dear Dr. Buzby:
On Friday evening-, January 9, I received as
visitors, by appointment, 2 gentlemen who sought
my approval of a plan to sell advertising space in
a Camden newspaper to the Camden County Medi-
cal Society or to individual members of that so-
ciety. They exhibited the advertising material pre-
132
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
pared by a publicity expert in Indiana, together
with a list of papers in which such ads have been
published, and letters purporting to endorse the
ads and the scheme in general. In the course of
conversation I was informed that they had asked
the county society $4000 for publishing 26 articles
at weekly intervals for 6 months, and that offer
having been declined they were seeking 80 sub-
scriptions from members at $50 each to pay for
such publication of said advertisements. They
further informed me that you and Dr. Lippincott
had refused to support the plan unless and until
the State Society gave endorsement thereto, and
that you had both advised consulting the Execu-
tive Secretary of the State Society.
I discussed the question with them in a friendly
manner and stated my personal objections, but
promised to think the matter over carefully and
without prejudice if they would leave the material
with me a few days. I have given the promised
careful consideration to this subject, in so far as
possible to all of its effects and ramifications in
addition to its primary results, and I have to
record the opinion that it would be unwise for any
county society or individual physician to partici-
pate in this scheme.
To the newspaper this is purely a scheme for
selling ad space— without even a pretense of in-
terest in physicians or public; a money-making
proposition — nothing else.
To the medical profession it is a cleverly worded,
alluring proposition to secure publicity without
violating the Code of Ethics. I have said that the
wording is a clever arrangement but I must add
that the choice of subject matter is anything but
clever. To harp upon the theme that physicians
are not promptly or adequately paid for profes-
sional services, weekly for 6 months, would be
mighty poor psychology — especially at a time when
there is so much discussion concerning ‘the high
cost of medical care’. Furthermore, the only ‘in-
direct advertising’ that organized medicine may
justifiably (?) engage in is paid-for publication of
the benefits which scientific medicine holds out for
the public welfare. This proposed advertising does
not fall within that classification.
I am returning the documents to the paper’s
representative, and most respectfully recommend
to you and Dr. Lippincott that your county society
members be advised to . have nothing to do with
the scheme.
Thank you most heartily for directing this mat-
ter to my attention, and thus affording me the
opportunity to become informed about another
scheme for separating the hard pressed physician
from his hard earned dollars.
Sincerely yours,
(signed)
Henry O. Reik, M.D.,
Editor & Executive Secretary.”
MEDICAL SERVICE OF THE FUTURE
1 hose of you who read the proceedings of
the Annual Conference of County Medical So-
ciety Secretaries and Reporters, in the Decem-
ber Journal, will recall the amount of discus-
sion devoted to so-called state medicine, and
you may remember that the Secretary of the
State Society gave a brief sketch of the steady
advance of governmental control of medical
practice, and the Executive Secretary alluded
to the suprisingly large number of articles upon
that subject that had been published in state
society journals in the short period of time be-
tween May and October 1930. We are still
hoping to find time to abstract those articles,
in order that a comprehensive survey of the
situation may be laid before you.
Recounting our vacation experiences, in the
January Journal, we announced the intention
to write later about the National Health Insur-
ance Act of Great Britain and the present status
of such legislation in England and in France.
We shall reach that point in our travel talk next
month, and will in successive monthly instal-
ments cjuote sections of the English and French
laws, together with authentic interpretations of
important features, so that you may have an
accurate picture of existing conditions.
Meanwhile we must keep an eye on the
progress of events nearer home. Legislatures
are at present meeting in most of the New
England and Middle Atlantic States and we
shall not be surprised if some radical proposi-
tions appear in several of the larger states.
Acts embracing centralized control of practice,
in one form or another, were under considera-
tion in more than one state legislative assembly
during the sessions of 1929 and 1930. In our
own state we had in each of those years to
combat an “Act to Control the Practice of Sur-
gery and the Surgical Specialties”. Most of
the Bills so far presented, whether applying to
surgery or to general medicine, have been so
extreme in their provisions as to kill them-
selves. But, it behooves us to continue watch-
ful and to study carefully every proposition
that is submitted, in order that we may act
intelligently, be prepared to support any move-
ment that gives reasonable assurance of bene-
fiting humanity, and to oppose any legislation
that experience leads us to believe would be
impractical, unworkable, or detrimental to pub-
lic welfare.
Our first duty is to become well-informed —
as thoroughly so as possible — regarding the suc-
cess or failure of such experiments elsewhere,
and concerning measures that have been con-
sidered or are being introduced in this part
of the world. It is that conviction, i.e., that
it is our duty to study this economic question
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
133
is scientifically as we would a newly proposed
remedy for some bodily disease, that induces
us to report upon the progress of events in
uther countries and to direct attention speci-
fically to projects that may suddenly present
themselves for decision. There is an old adage
that “where there is so much smoke, there must
be some fire”. Generally, there is some good
reason, some degree of truth, back of or under-
lying any public clamor that persists for an
appreciable length of time. Many of the books
and articles criticizing the medical profession
and threatening dire consequences if practice is
not immediately revised, have been ridiculous,
and not a few of them evidently inspired by
prejudice, even at times hatred, based upon
ignorance or falsehood. Not infrequently a
sound basic complaint has been exaggerated
and distorted and expanded into an unreason-
able protest supported by an illogical argu-
ment. But, we must admit that there have been
some reasonable complaints, some justifiable
protests against harmful procedures that have
grown up in and become fastened upon the
modern practice of medicine. These abuses
must be corrected, and we are confident that
none will excel the great mass of honest physi-
cians— 90%, at least, of all members of the
urofession — in applying the corrective, once it
has been judicially determined what is wrong
and what is the remedy.
Admitting for the sake of argument, that
the present state of unrest and of dissatisfac-
tion with medical practice is in some measure
justified, let us inquire whether state medicine
is the proper, the best, or the only remedy.
When its proponents have presented their case,
we shall be in a position to answer, to argue,
and, if necessary, to contend for an honest and
just decision. Flat denunciation of any pro-
posed change, especially if the proposition be
vague and poorly understood, is futile. If there
is anything radically wrong with the custom-
ary procedures of professional practice we want
to know it. If there is a better method of prac-
tice we want to adopt it. If the great benefits
of medical science can be more effectively sup-
plied to a larger percentage of suffering hu-
manity; if by a change of procedure we can
more quickly wipe disease from the face of the
earth; if there is a more rapid, more efficient,
and more generally satisfactory means of bring-
ing about the millennium — for Heaven’s sake,
let’s have it ! Whether it be called state medicine
or by some other euphonious term matters not ;
to us, “a rose by any other name would smell
as sweet”.
Asking for information — what is state
medicine — it would seem wise to direct the
query to one of its most prominent advocates.
In so far as we have seen, the most logical
presentation as yet made of a concrete plan
originated with the author of the Bill that, was
last year before the Legislature of Massa-
chusetts, and with a view to securing for your
consideration the best possible statement of the
fundamental facts to be embraced in a pro-
posed American system of state medicine, and
the soundest reasons in advocacy of such a
system, we invited Dr. Gilbert W. Haigh, of
Worcester, to prepare for us the paper which
you will find under the title at the head of
this editorial. Dr. Haigh is a worthy member
of our profession, who, in addition to exper-
ience as a general practitioner in private prac-
tice, has served in the Medical Corps of the
United States Navy and he knows whereof he
speaks. Here is no “sensationalism”, no carping
criticism, no threat of punishment for mis-
deeds or short-comings ; here is a plain,
straight-forward discussion of conditions un-
satisfactory to the profession as well as to the
public, and a tempered argument in favor of
one method of socializing medical practice. It
is constructed by “one of our own”, who has
given much thought to this very serious prob-
lem and who offers what he believes to be the
best possible solution.
ADDING INSULT TO INJURY
BRAZEN EFFRONTERY OF THE
AMERICAN TOBACCO COMPANY
Has your quiet evening enjoyment of the
radio ever been disturbed by the raucous voice
of the Lucky Strike announcer, informing the
world that “Luckies are kind to the throat”?
Has your blood boiled because of the heat en-
gendered by his slanderous pronouncement that
“20,679 physicians have stated Luckies to be
less irritating” to the throat and less likely than
other brands of cigarettes to induce coughing?
134
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
Have your respect for science and love of truth
suffered under his deceitful, tricky, distorting
use of the language of science to bolster up an
alleged scientific treatment of tobacco to im-
prove its quality?
Until recently you might have supposed the
manufacturers of “Luckies” had sunk about
as far as one could go in tbe slime of dishonest
advertising, but there remained at least one
lower level and the company has descended to
that stage; and for brazen effrontery it takes
the blue ribbon. We do not know exactly what
has happened but apparently something trans-
pired to make the company’s publicity agent
realize that the usual radio talk constituted an
insult to the medical profession. In conse-
quence, it would seem, the speaker now occa-
sionally throws out what he probably considers
“a sop to Cerberus”; i.e., a gratuitious an-
nouncement (in a tobacco advertisement) that
periodic health examinations are or should be
beneficial, and advising individuals to visit their
family physicians at regular periods. Can you
beat it? Insult added to injury! Evidently the
sponsors of that program believe they can in-
sult and slander physicians ad libitum, and
then palliate the offense by publicly endorsing
a welfare movement that was inaugurated by
physicians as part of a disease prevention pro-
gram. What next?
Quite aside from its offensive character, as
viewed by physicians, the Lucky Strike adver-
tising matter is about the worst that the Ameri-
can business craze for blatant, impudent, false,
not-quite-provable-lying adveftisements has
yet produced. Let us analyze the speech that
is repeatedly broadcast and the wording of ads
now appearing in daily papers like the New
York Times and magazines like the Forum;
publications that ought to be but are not above
engaging in the spread of such deceptive and
misleading material.
I he statement that 20,000 physicians signed
cigarette testimonials may be true, though we
doubt it. But, if it be true that so large a num-
ber of educated men could be induced to “sign
a blank check”, the fact must not be over-looked
that in this instance the signatures were secured
by methods which smack of fraud. While we
feel ashamed of the fact that so many of our
brothers proved themselves “easy suckers”, the
advertiser who procures testimonials through
deceptive procedures has little to be proud of
or boast about.
The statement — “It’s toasted ! Everyone
knows that heat purifies and so toasting re-
moves harmful irritants that cause throat irri-
tation and coughing” — is made to appear as
evidence of a scientific fact, but is, in reality,
nothing but a jumble of words covering 3
alleged facts which have no true relationship to
one another. For instance: “Everyone knows
that heat purifies.” We might retort that every-
one knows also that heat destroys. What rea-
son is there to suppose that heating will purify
tobacco? We may assume the answer would be
that heat is destructive only when applied in
an intense form, and that purification attends
upon the use of heat in n oderate degree. Very
good, but if by “purifies” it is meant to imply
that microorganisms — disease producing germs
— are destroyed, we respectfully submit that a
considerable degree of heat is required for that
purpose, repeatedly applied in the case of spore-
bearing germs, and that the heat of toasting is
not sufficient to accomplish the purpose. A
very simple experiment can be tried in the
kitchen. Would any bacteriologist testify that
toasting a slice of bread will destroy pathogenic
germs on or in that bread, and thus purify it?
We think not. Which disposes of that al-
leged fact.
Perhaps germs were not meant ; we admit
they were not mentioned, but we are unable
to think of any other form of purification that
could have been alluded to in that statement.
1 he second alleged fact (or is it a deduction
from the previously alleged fact) is that “toast-
ing removes harmful irritants”. What irri-
tants.'' Bacterial, as referred to above, or chemi-
cal : 1 f the claim refers to chemical substances,
pray tell us what chemical irritant can be re-
moved from tobacco by the simple process of
toasting . We have some knowledge of
chemistry but need help to solve that problem.
1 hirdly, it is stated that toasting removes
irritants that cause throat irritation and
coughing . Again, may we ask what is the name
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
135
and nature of these irritants (characterization
of a single one will satisfy our personal curi-
osity) that irritate the throat and induce
coughing? If the claim can be sustained, that
smoking tobacco or cigarettes of any kind
produces of itself a specific irritation of the
throat and a characteristic cough, there are
several thousand specialists in affections of
the throat who will welcome proof thereof,
and who will be particularly glad to be en-
lightened as to the specific nature of the irri-
tant.
But that is not all — we had almost forgotten
the greatest claim of all : “Everyone knows that
sunshine mellows— that’s why toasting includes
the use of the Ultra-violet Ray.” Ah ! What
a lucky strike ! Ultra-violet rays (why not vi-
tamins)—Uads of the day — must be worked in
to aid the old-fashioned toasting. “Sunshine
mellows” — perhaps, but who has proved that
it is the ultra-violet end of the spectrum that
produces the mellowing efifect, on fruit for
instance, and what constitutes the mellowing
of tobacco? Like Hashimura Toga, “we ask to
know”.
What, then, does our analysis show? In plain
English, it shows that the bombastic radio an-
nouncement and the printed advertisements re-
ferred to are a tissue of falsehoods strung to-
gether in such an impressive manner as to
deceive the simple-minded listener and reader,
and the advertiser doubtless hopes that repeti-
tion of deceptive statements will give them the
effect of truthfulness. And the medical pro-
fession is made to appear as endorsing all this
tommy-rot.
What can we do about it? Shall we, 100,-
000 or more physicians, supinely submit to
these nightly radio and daily newspaper in-
sults of the Lucky Strike manufacturers, or
shall we make some effort to suppress such ad-
vertising and to protect the public and our-
selves against misleading, deceptive and slan-
derous broadcasting, whether by radio or print-
ing?
You may recall that the old slogan of this
same Company — Reach for a Lucky Instead
of a Sweet — was quickly withdrawn when the
sugar trust aided the candy-makers in a de-
mand for suppression.
Special Article
MEDICAL TRAVEL TALK
A Physician’s Vacation in Ireland, England
and France
Henry O. Reik, M.D.
(Continued from January Journal)
Leaving Ireland by the route from Kings-
town to Llolyhead, we spent a week touring in
Wales, en route to England; passing from the
Castles of the Donohoes and the Mahoneys to
the Castles of the Conways (somewhere along
the line an extra letter “a” seems to have been
inserted by the American branch of the last
mentioned family). Rain pursued our foot-
steps but whereas it had been mist in Ireland
it became a soaking and a cold rain in Wales.
The country, too, changed from rolling hills
and valleys covered with lush verdure, to bar-
ren, rocky, wild scenery with rushing streams
and waterfalls, and even in August it was
necessary to have a fire in our room after din-
ner or go to bed to keep warm. Wales does
have the advantage of being a compact little
country with much of natural beauty to in-
terest the tourist and its most charming places
made easily accessible. Travel by automobile
buses has “caught hold” in Great Britain, and
one can travel readily and cheaply from point
to point by that means of locomotion. So,
with Conway as headquarters, we made day
trips to Llandudno, Colwyn Bay, Bettws-y-
Coed, and other prominent resorts.
It was amusing to compare the famed Welsh
seaside resorts with those of our country —
particularly because the most famous, Llan-
dudno, is advertised as the “Atlantic City of
Wales”. How the comparison first arose is
incomprehensible, for there isn’t the slightest
resemblance of one to the other. It was pitiful
to see the children hunting for a patch of sand
in which to dig, when the tide was out (the
beach being covered with rocks and pebbles)
and to watch those courageous enough to take
a bath running into the water for a momen-
tary dip and coming out shivering, to snatch
robes and run to the bath house. ' These re-
sorts. are famous only because they are all the
country has to offer its people, and it is easy
to understand that the inland city dweller and
the invalids are glad to visit the coast occa-
sionally to breathe a cleaner and more sooth-
ing air even though sea bathing facilities and
comforts are not to be had.
Even the casual tourist cannot help feeling
Puritanism in the Welsh atmosphere, especially
if he is familiar with the general European
136
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
conditions; a puritanical frame of mind that
extends even to the naming of places and
things. An amusing example was observed in
certain retreats which were labeled “Public
Conveniences”, and the 2 sections were mark-
ed lavatories for men and cloak rooms for
ladies ; which we admit is a bit more esthetic
than the customary signs elsewhere.
To us Wales was essentially a country of
castles and feudal estates. We were impressed
by those impregnable, medieval fortresses,
high, crenelated towers with slits like sword
gashes in their sides, and with stone walls and
strong iron gates that looked down as if dazed
by the modern automobile buses scurrying
along the highway. The castles seemed to play
hide and seek with passers-by as glimpsed
over the wall and through the surrounding
charming remnant of medieval history. Let
no one visiting England overlook Chester, for
it is a very delightful place in itself and it is
an excellent center from which to visit other
noteworthy Welsh and English historic spots.
For instance, it was from Chester that we em-
barked on a tour of the English Lake Region,
going by train to Windermere and thence by
automobile in a circular trip about the lakes,
with stoppings at various sites to pay our re-
spects to Wordsworth, Southey and Coleridge
- — for, as Moore sang of Killarney, and Burns
and Scott of the banks and braes of Bonnie
Scotland, these English poets found their hap-
piness and inspiration on the lovely shores of
Windermere, Rydal and Thirlmere. Liking
one place better than another is purely a mat-
ter of personal taste, or of some fortunate ad-
Fig. 1. Carnarvon Castle. Heraldic Home of the Prince of Wales
forests ; ivy-covered walls and marvelous old
trees that have withstood the storms of innu-
merable years, and a profusion of brilliantly
colored flowers, especially rambler roses,
against the slate gray houses. What a sense
of security the barons must have had behind
those walls, when the gates were closed and the
drawbridge suspended in the air.
Conway Castle at the head of Conway Bay,
in a town that is further protected by a harp-
shaped wall, is one of the best preserved in
Wales; sharing that distinction with Carnar-
von, birthplace of the first Prince of Wales,
later King Edward the First, and scene of in-
vestature of the present Prince Edward, heir
to the throne, who is so deservedly popular.
Entering England by the gateway of Ches-
ter, we were immediately fascinated by that
venture, and it is rarely safe to recommend a
given place by using the most superlative ad-
jectives in comparing it with others; for us,
the Irish, English and Scotch lakes each has
its special charms and any of them would be
satisfying as our “little bit of heaven” in
which to spend the remaining years of life.
Wordsworth’s Seat, a massive rock situated
in a grove of evergreens overlooking beauti-
ful Rydal Water, gave us an hour’s delightful
repose amidst scenery that might well inspire
anyone to poetic discourse on the loveliness of
nature. Dove Cottage, at Grasmere, his
home from 1799 to 1808, was less inspiring
but afforded some thrills from intimacy with
his earthly possessions, at the same time that
the visit aroused pity that so noble a man, such
JOURNAL Or THE MEDICAL SOCIETY OF NEW JERSEY
137
Feb., 1931
a benefactor to mankind, had been compelled
to live in such evident poverty and discomfort.
Visiting the old church, St. Mary’s, at Ry-
dal — an accidental visit occasioned by our seek-
ing refuge from a shower of rain — we dis-
covered a gloriously colored, stained glass win-
dow (St. Luke and St. John) in memory of
Wilson Fox, M.D., Physician-in-Ordinary to
Queen Victoria, and who died in 1887 ; and. a
bronze tablet to the youngest daughter of Dr.
Matthew Arnold of Rugby, who had “served
her community faithfully and well for 75
years”.
Returning to Chester, and its own particular
charms, let us recall that it is one of the very
few cities that can today boast of an entirely
surrounding old Roman wall (almost perfect-
ly preserved by some bits of restoration), upon
handsomest and best preserved bearing the
date 1503) are quite remarkable, the style of
architecture being peculiar to the place, and
the carving upon posts and lintels, and the
mural decorations, being entertaining and in-
structive. Thus, Bishop Lloyd’s house pre-
sents some rare wood carving illustrative of
religious history, and God’s Providence House
a dedication which proves the original owner
to have been an egotist of supreme degree. Ac-
cording to popular belief, the inscription — -
“God’s Providence is mine inheritance” — was
added after the plague which ravaged the city
during the seventeenth century ; this was the
only dwelling in Watergate Street which the
plague passed over; and in gratitude for that
remarkable deliverance, the owner had the in-
scription carved on the main beam.
Fig. 2. Rydal Water. View from Wordsworth’s Seat.
the top of which one can promenade entirely
around the city, a distance of about 2 miles.
Then, in the very heart of the city, and more
curious even than the wall, are the old “rows”
— a double-deck sidewalk that affords passage
for pedestrians in front of shops occupying
both the first and second stories of the build-
ings. It is worth noting that this plan of build-
ing (probably of Roman origin) was estab-
lished in Chester something like 400 years ago,
and that only recently our exceptionally mod-
ern city of New York has been considering
the advisability of construction upon such a
plan to relieve sidewalk traffic congestion; an
excellent example of the manner in which civ-
ilization, so-called, progresses in circles. Some
of the older buildings in Chester (one of the
Blossom’s Hotel, on Foregate Street close
to the main gateway through the wall, is cen-
trally located and furnished the most com-
fortable and satisfactory accommodations we
had thus far encountered on the trip. All
points of interest were close at hand, and Ches-
ter Cathedral, particularly, proved worthy of
several visitations. It is one of the few cathe-
drals which, at least so far as we are aware,
seems not to have been awarded its due meed
of advertising. Its friendly atmosphere —
signs everywhere bidding you to enjoy this or
that special feature — as well as the old Nor-
man architecture produced a pleasing effect;
and the cloisters of the old Abbey were among
the finest we have ever seen. There, too. we
stumbled upon a tomb inscribed : “William
138
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
Makepeace Thackery, M.D., Educated at
Trinity College, Cambridge.”
We chanced to be in Chester on August 21,
when the Duchess of York gave birth to a
daughter — “the first Scotch Princess for 300
years”. At breakfast in the hotel next morn-
ing we found all the British guests devouring
the newspapers and excitedly discussing the
great event. Our waitress was as happy as if
she, herself, had contributed this gift to the
Empire, and was delighted by our willingness
to listen and our expressed participation in the
joy of herself and her nation. With the best
of good will toward the Duke and Duchess,
and appreciation of English feelings and cus-
toms, we could not, however, help but enjoy
the following sentences from the morning pa-
per (Daily Herald. London, Aug. 22, 1930),
We abandoned Chester with considerable
regret and proceeded to London. Of that
great city we shall have nothing to say here
except regarding the practice of medicine. Our
interest this time was principally to learn
something about the working of the National
Health Insurance Act, for we happened to
have been in England when that law was en-
acted in 1911, and to have been confused ever
since by the conflicting reports of its success
or failure. Before taking up that matter, how-
ever, and comparing the progress of medical
socialism in England and France, permit us to
say a few words about medical study abroad.
It has always been surprising to us that so
few American medical students take advan-
tage of the opportunities for post-graduate
study in England, where knowledge of the
Fig. 3. The “rows'’ on Chester’s main street.
descriptive of the royal happenings at Glamis,
Scotland :
“The reception of the baby Princess into this
world was Wagnerian in its tumult.
Thunder pealed, lightning flashed around the
castle, and the wind whistled through the trees.
The anxious crowd of motorists waiting in the
driving rain and pitch darkness outside the walls
of the castle, watching the lighted window of the
room on the second floor of the castle where the
baby was born, saw the towers and pinnacles of
the castle silhouetted vividly in the lightning
flashes, and at the moment when the baby was
born there was a terrible peal of thunder.” (Italics
ours. )
In such manner does nature aid obstetrics
in the advent of a royal daughter ; we are
staggered by contemplation of what cataclysm
might have attended upon the advent of a son.
language enables them to understand what they
see and hear ; and that so many proceed in-
stead to lectures and clinics in other coun-
tries, of whose language they have little knowl-
edge, and where it is only with the greatest
difficulty that they can understand fragments
of lectures and not infrequently make an in-
correct translation of those portions. The
abundance of clinical material, in general
medicine and each of the specialties, in Lon-
don. Liverpool, Glasgow and Edinburgh, is
evident, and in most of the specialties teach-
ers of the highest standing are available. It
is true that clinical material is not as well
organized for teaching purposes in those
cities as one finds it in Germany but, on
the other hand, the teaching seems to us bet-
ter. It depends, of course, to a large ex-
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
139
tent, upon what one desires. If one wishes to
gulp his medicine in concentrated form, pack-
ed in a capsule and administered in specific
doses, then Berlin and Vienna are the places
for study. By way of comparison we think of
the teaching in German institutions as some-
thing akin to the American business idea of
efficiency and standardization, with lectures
given in the most dogmatic manner, with lit-
tle or no opportunity to consider other opin-
ions, and the end-product to be a machine-
made doctor housing a number of fixed be-
liefs; while the English teaching, by contrast,
is more comprehensive, considers all aspects
of a problem, and is designed to turn out a doc-
tor capable of thinking for himself. To our
own way of thinking, the English system is
during the summer months, these famous uni-
versities are happy hunting grounds for the
scholastic. To prowl at will among those
charming old buildings, to feast one’s eyes
upon their artistic construction, to muse upon
the hundreds of great men who have through
the ages studied and taught science within
those sacred precincts, to walk with their
ghosts from gateways to chapels, should' fill
even a simple-minded medical tourist with re-
spect for knowledge and enjoyment .of the
happy brotherhood of students. Temptation is
strong to write now of the 20 or more colleges
that make up each of these great universities
but we shall confine our references to a few
that most impressed us. At Cambridge, for
instance, we felt a peculiar attachment to
Fig. 4. British Medical Association Building, Tavistock Square, London.
preferable. As regards other countries, France
and Italy, particularly, we may say that abund-
ant material exists for study, and in some
cities — Paris, Bordeaux, Marseilles, Rome,
Florence and Naples — there are exceptional
facilities for investigation provided one under-
stands the language and is sufficiently inter-
ested to explore upon his own account. In
Paris and Bordeaux a few special courses are
well organized ; in the Italian cities there is a
wealth of clinical material in general medicine
but there is little organized teaching.
From London we made 2 pilgrimages of in-
terest ; one constituting our third visit to Ox-
ford, and the other providing our first view
of Cambridge University. Fairly deserted
Caius College, the main entrance to which is
called the Gate of Humility. “Through this
portal arrived the eager schoolboy and he
walked along a shaded path till he reached a
second, and more resplendent archway — the
Gate of Virtue. Through this inner entrance
he passed to his residence chamber, and lead-
ing the virtuous life upon which he had em-
barked he came ultimately to pass out by the
Gate of Honour to take his degree at the Sen-
ate House.” Founded by a doctor, Caius Col-
lege has always been a home of medical learn-
ing, and among those who once passed through
the Porta Honoris, was the great William
Harvey, discoverer of the blood circulation.
At Oxford, probably because we had so of-
140
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
ten heard Sir William Osier speak affection-
ately of them, we admired most Magdaleine
and Christ Colleges— in the latter, reading the
name of Osier’s only son inscribed upon the
marble scroll of honor among those who gave
their lives in the World War — and the Bod-
leian Library which was very close to Sir
William’s heart.
Now, returning to observations made dur-
ing this summer’s visit to London, let us say
that we avoided hospitals and paid attention
only to medical economics. We did take a look
at the magnificent old homes of the Royal Col-
lege of Physicians and the Royal College of
Surgeons, and then visited the handsome new
buildings of the British Medical Association
on Tavistock Square.
At B. M. A. Headquarters we made the
acquaintance of the Deputy Medical Secre-
tary, Dr. G. C. Anderson, in charge during
the absence of Secretary Cox, who was then in
Canada attending the British Medical Asso-
ciation Convention, and in addition to show-
ing us through the new building Dr. Ander-
son was extremely kind in supplying informa-
tion relating to the practice of medicine in
Great Britain. From him we secured also lit-
erature bearing upon the association’s work.
What we shall have to say concerning Brit-
ish medical affairs is the outcome .of person-
al observation and of conversations with a num-
ber of physicians, including Drs. Russell and
Hennessy, in Dublin, and Dr. Anderson, in
London, but we are solely responsible for in-
ferences and conclusions and trust our read-
ers will not hold any of the above mentioned
persons responsible for our views; such views
being a composite of impressions from many
sources.
Our attention was attracted first to adver-
tisements indicating that insurance in the na-
ture of defense and protection against mal-
practice suits is just as necessary in England
as in the United States, but some of the pub-
lished matter left us in doubt as to whether
such insurance was offered by the national
medical society. That was straightened out
for us and we learned that there are 2 policies
available to physicians and surgeons ; one with
the London and Counties Medical Protective
Association ; the other offered by the Medical
Defense Union ; each being essentially the reg-
ular type of insurance company. The Brit-
ish Medical Association has more than once
considered the plan of self-insurance of its
members but has so far resisted that proposi-
tion, and at present the officials look upon the
Defense Union as the more satisfactory of the
2 companies named above. The initial charge
is 10 shillings ($2.50) and annual premium
£1 ($5), for which subscribing members are
entitled to unlimited defense and indemnity.
The plan in vogue, then, is similar to our own
group insurance but seems to be less expensive.
We were most anxious to learn something
positive and exact about the status of the
National Health Insurance Act and its effect
upon the medical profession. As stated be-
fore, we happened to be in England when the
law was enacted, in 1911, and again in 1912
and 1913 when opposition of the organized
profession was very pronounced. Even in la-
ter years some British medical journals, and
letters from British correspondents published
in the Journal of the American Medical As-
sociation, have continued to criticize the scheme
and to point out flaws in its construction and
objections to its application. We were, however,
at the same time aware of the fact that many
practitioners in England and Scotland looked
upon it as a beneficent law ; a law which, like
many others, had some objectionable features,
or that was susceptible to abuse, but which
benefited much more than it harmed medical
practitioners. Recalling some of the praise we
had heard, especially from country practition-
ers, we have been surprised at times to read
articles declaring the whole plan a failure and
the very special bete noire of British physi-
cians. After a time we arrived at the con-
clusion that objections came mainly from the
highly business-successful practitioners, and
that the average family doctor was willing to
admit that he had gained, in a financial sense
at least, from application of this law. Fur-
thermore, it became evident that much of the
criticism dealt with minor defects in the law
and major defects in human nature, and con-
sisted not infrequently in exaggerated state-
ments, verging sometimes upon falsification.
For instance, within the past year we have,
in some of our best American journals, read
denunciations of the law based largely upon the
allegation that “the patient is deprived of his
right to choose his own physician” ; a mis-state-
ment of conditions that has been repeated hun-
dreds of times and which could readily have
been avoided by looking at the written law. For
these reasons we wanted to get at the facts
and, consequently sought interviews, asked
questions and secured copies of authoritative
documents. So, next month we shall present
comments upon the existing law and upon the
recently proposed extension Act.
(To be continued.)
Feb., 1931
141
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Esthetics
RECOGNITION OF HOME TALENT
Ic has been our custom to employ bits of
poetry now and then to fill an unexpected
space in the Journal, to enrich a tribute to
some departed brother, or to enliven and en-
tertain our readers. On several occasions we
have enjoyed the privilege of presenting orig-
inal poems contributed by members of our own
state society. Never before have we devoted
all of this departmental space to poetry but as
we have at hand some material that has al-
ready awaited publication far too long a time
because we could not find an appropiiate
Journal opening, we have concluded to offer
you in this issue 2 contributions from the pen
of Dr. Cone, and 1 from Dr. Corson — both of
whom, as you well know, are prone to give
vent to their feelings in rhymthic verse.
THE WAR NURSE’S STORY
Ralph S. Cone, M.D.,
Westwood, N. J.
(Written January 1918.)
Some folks think we nurses are heartless,
How little they know, to be sure,
When they say that our hearts become hard-
ened
Because of the sights we endure.
Though we can’t let our feelings be master
And must have control of our heads,
Please don’t believe we are all alabaster,
With hearts like our hospital beds.
I could tell you, sir, many a story,
Nightmares from the lines of the French;
We have cases I hardly dare think of
Brought in from the field and the trench.
I’ve nursed all sorts and conditions,
The coward as well as the brave,
The good and the bad, the indifferent,
And know how each can behave.
I have loved and been loved by the grateful,
Been insulted and cursed by the bad
All kinds are brought in to us here, sir,
And some cases are terribly sad.
There was one, not so long ago, either,
Of a poor little bairn we had here,
I say bairn, but he was a soldier,
In age about twenty-one year.
Well, he was brought in, I was saying.
It had been a hard day and ’twas late,
He came with a number of others
All scorched to the color of slate.
Just breathing they were when they reached us
And gently we cut off their clothes,
Or what there was left of their garments,
For not much remained but their shoes.
Their heads were as bare as their faces,
There escaped hot a vestige of hair,
Their features were like nothing human
And their eyes had a horrified stare.
There were ashes and dirt clinging to them
And the smell made me dizzy and queer,
Though the doctors said they didn’t suffer
And they’d all quickly die, it was clear.
Well, it fell to my lot to nurse this one,
I whispered a prayer and began
To take charge of my terrible bundle
That bore the rough shape of a man.
Ah, we do grow fond of our patients,
What injustice to say ’tis not so!
I think, sir, that those who say such things
Have never been where they could know.
How can a nurse fathom the feeling
She has for the helpless and ill?
As a fond mother loves most her weakest,
She loves those who most need her skill.
Well, my boy passed this night and the next
one,
My duty was his case alone,
All the others had died except him, sir,
And I took him all for my own.
’Twas a labor of love as you might say.
How I watched every breath that he drew,
And at times he would seem to be conscious,
But what he thought nobody knew.
The doctors all marvelled he rallied
And they said if his temperature rose
’T would mean rally from shock at the most
sir,
But my brave fight they feared I must lose.
I rebelled at their verdict and nursed him
I knew that he lay at death’s door,
But I prayed to the good God to help me
As never I’d prayed, sir, before.
There he lay, like a ghost on his pillow,
His face all enswathed in a mask
His arms resting still alongside him
No complaint and no questions to ask.
Then came what the doctors predicted,
He rallied and I watched and prayed
So far God had seemed to be with me
And the cruel hand of Death to be stayed.
My ward here was crowded with soldiers.
Each bed held a victim of war,
And the dull heavy booming beyond us
Made it plain we’d soon have many more.
Every hour they’d come in on stretchers,
Poor bodies all shattered and torn,
While our doctors worked on like grim de-
mons ;
Brave Heroes ! Thank God such are borni
142
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
My helpers at this time were many,
Extra nurses to us had been sent,
That’s how I was spared to my soldier,
My own now by common consent.
In the ward we’ve a box of tin soldiers
The recovering men use as toys,
They amuse themselves, sir, by the hour
Just like great big over-grown boys.
J think there’s some fifty or sixty
All painted in dirt colored hues
To represent men in the trenches,
No scarlets nor grays, sir, nor blues.
Our men have them labelled by nations
And arranged in the proper array
They form them in different positions
And battle it over each day.
Though he seemed to grow weaker and thinner
And his poor senses going a bit,
My bairn followed the games of the soldiers,
I could see by his eyes through the slit.
Well, he lay in this state a whole fortnight,
Being fed through a tube in his nose,
For he’d breathed in the flames and to swallow
Brought on the most terrible throes.
One night between midnight and morning
I thought that I noticed a change, •
’Twas like a mysterious warning,
An uncanny thing, and so strange;
The ward light had sunk in its holder
So low it had almost gone out,
When I looked at my boy on his pillows
And saw his hands groping about.
Quick I made a new light and came to him,
Took his pale, waxy fingers in mine
And said “Laddie”, but he was past knowing
And I felt there the Presence Divine.
I watched him perhaps half an hour,
Lying there like a fluttering bird,
When all at once up from that bed, sir,
Came the sweetest voice ever I’d heard :
“Dear Nurse, won’t you bring out the soldiers
And set them up where I can see,
It’s dark, but I know you can find them
You’ll put them up, won’t you. for me?”
Sir, these were the first words he’d spoken
And they came from the pillows so clear;
But I knew that they couldn’t be natural
With Death’s Angel waiting so near.
When I’d set up the soldiers I watched him,
He just seemed to rise in his bed
And reach his arms out toward the candle
And that’s all I know — he was dead.
The nurse bowed her head on the table,
No more could the good woman say.
There I left her alone with her reveries
And. silently passed on my way.
REQUIEM TO THE UNKNOWN
SOLDIER
Ralph S. Cone, M.D.,
Westwood, N. J.
(Written December 10, 1929.)
A silent mass before this brass,
Stranger, it is his due !
For o’er this grass ye shall not pass,
But pause this shaft to view.
Perchance ye came to read some name
Emblazoned bright as day ;
Not to his shame, unknown to fame
llis name rests with his clay.
Or, knowing all, ye felt the call
To mourn the Unknown Dead,
To here let fall in Memory’s hall
A tear above his head.
The foe to block and kings unfrock,
With steady eye and hand
While earth did rock he braved the shock
And shell of No Man’s Land.
These wind-swept mounds are hallowed
grounds,
This shaft his resting gun,
Ynd peace surrounds, no more the sounds
Of war his senses stun.
Ve placed this stone o’er the Unknown,
It giveth him no pain.
But hark his moan, “Lest ye atone
Our sacrifice is vain”.
No cenotaph nor epitaph
Can make him live again
Till holier deeds than his must needs
Arouse the awe of men.
No mortal praise his form can raise
Nor should ye cry, “come forth”
But meet his gaze through battle’s haze
And show ye know his worth.
Why weep ye so as on ye go
With many a pensive sigh !
1 tell ye though ye laid him low
His God hath raised him high.
PHLEBITIS
E. S. Corson, M.D.,
Bridgeton. N. J.
A gray little nerve cried an alarum
For a little blue vein suffering harm.
“Its walls are swollen turgid and thick,
I am sure its owner must feel very sick”,
And its owner feeling something awry,
Feb.. 1931
JOFRNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
143
For pain and anguish raised up a cry
The doctor came in with a wise look and said :
“I advise this patient at once put to bed,
Keep two little bulbs steady and bright
Burning away, all out of sight ;
Doing their duty in regular form,
Under the covers cosy and warm.
Patience, pluck, perseverance and prayer.
Are needed indeed to make a repair,
With pillows and crib and leg elevated
Four weeks in bed surely you’re slated.”
The little corpuscles got in their work,
Nor did the blood plasma any bit shirk.
They hurried by night as well as by day,
For the two little bulbs lighted their way.
Nor once did the cold their mission delay,
The heat made their vigor more strongly dis-
Pla>\
With petting, nursing, flowers and fussing,
Time went apace and pain went a buzzing.
Medical Ethics
MORE HEALTH ETHICS
John Hammond Bradshaw, M.D., F.A.C.S.,
Orange, N. J.
When Walter Camp published on August 5,
1920, in Collier's Weekly, his article on “The
Daily Dozen”, lie really started something.
Born in 1859, Camp was then just 61 years
of age, and like the beer that (once) made
Milwaukee famous, it was Walter Camp that
made Yale College famous as a center for all
the best there is in college athletics and foot-
ball activities. And now, his “dozen" has made
Walter famous.
Before this, notwithstanding the fact that
the country was full of “deflated men and in-
flated women”, calisthenics per se had never
been popular. A well-advertised magazine on
Physical Culture had long told us that exer-
cise was the only straight and beautiful road
to health. But, sad to relate, if one accepted
the statements in this gem of literature, doctors
were themselves the chief obstructionists to at-
tainment of this blessing. The “big idea” seen
in the pages of that magazine was that it was
idle to throw down a medical pill when you
could obtain your objective in throwing up a
medicine ball ! To make calisthenics popular,
beautiful girls, with all their curves, gave each
page a pictured charm. Male ditto almost
made one think that by following suit he, too.
could make his life sublime; and if he had any
doubt of this it was only necessary to read the
any pages of advertisements.
It seems a pity that this magazine still takes
delight in knocking the doctors, for they might
easily be won over to the cause. Doctors are
just as much interested in health as they are
in sickness ! They also cultivate their own
muscles — vide any afternoon on any golf
course.
We live now in a standardized world. I
doubt if Walter Camp, away back in 1920,
when he advocated his daily dozen under the
classified titles of
( 1 ) heads
(2) hands
(3) hips
(4) grind
( 5 ) g rate
(6) grasp
The Daily Dozen
( 7 ) crawl
(8) curl
(9) crouch
(10) wave
(11) weave
(12) wing
ever intended them to be strictly standarized
for the whole family from the baby to grand-
ma.
Nowadays, we eat to the accompaniment of
jazz and naturally it follows that our morning
set-up should have the same incentive. It is
debatable whether this very much aids our di-
gestion ; but possibly the timing and rhythm
keep us bravely on our morning chore. It does
appeal to the youngsters, I admit. Some say a
few properly selected personal exercises would
be better adapted in isolated cases.
The human race (not using the word in the
sense of speed) is peculiar. We really do
hurry from one thing to another and often
discard the good for something that is new.
We are informed that Chauncey Depew
lived into his 94th year and never walked a
block (if he could help it). Our own Thomas
A. Edison is going strong at 83, yet I have my
doubts (being his personal physician) if he
ever wants to exercise any part of his anat-
omy except those parts above his collar. Here
by contrast, you have Walter Camp dying of
heart disease in his bed at night in his 66th
year.
Exercise is. however a good thing for the
physical well-being of any animal, human or
otherwise. There is no doubt that most mus-
cles crave work. Did you ever see a team of
huskies at their job? How do you explain
the joy in mountain climbing which often dis-
regards all danger? Watch sports on track
and field.
Any exercise can be taken in the wrong way,
with resulting harm and resulting damage. It
144
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
has often been remarked that all this can be
avoided. Doubtless there are many who
should not even attempt the morning set-up.
Now, this is important — “the real value of set-
ting up exercises comes through the circula-
tory system, the breathing and the general car-
riage” , and all this can be effected in a short
space of time with little effort, but the effort
must be daily — it must be routine. Remem-
ber if you are set down instead of set-up, you
must leave it alone.
Did you ever regard your side view in a
long mirror with all your clothing removed?
You will probably receive a shock ! What dis-
pleases you can be corrected by suitable set-
ting-up exercises. If you are a business man,
it is foolish, intending to catch the 7.57 a. m.
train to arise at 7.23, rush through your daily
dozen, wash, shave, stop at the closet, eat your
breakfast, kiss your wife and your five chil-
dren, catch your train on a rush, and expect
to be much benefited by these maneuvers. You
must be willing to sacrifice a little of your
sleep. The funeral is always your own.
As one goes along in life, and gets older,
one should be more and more careful about the
proper exercise to be taken. To a certain les-
ser extent this is true even in youth. Do we
as doctors not believe that competitive athletics
have their danger? Can we believe that the
violent exertion of winning a crew race is of
very much benefit to the health? It is not so
very unusual to see some members of a com-
peting crew, at the finish, fall back in their
boats insensible, and sometimes even spit
blood ! Did you ever watch the facial expres-
sion of the flat or hurdle racer as he nears the
tape? “One must put in it all that one has
got and then some” to win the prize. And
what prizes do they often win in later life?
Possibly a dilated heart that certainly cripples
their declining years. Do you think that Wal-
ter Camp’s death from heart disease was in-
fluenced by the intense football activity of his
youth ?
Go with me into the locker-room of any
golf club and see the old men come in after
their day’s sport. Some are hollow-eyed and
show absolute fatigue ; some show cold hands
and a leaking skin. How many of them will
you find who at once call for a high-ball or a
cocktail? This is not a diatribe against golf,
to which the writer is absolutely sold. It only
shows that when one engages in athletic ac-
tivity after a certain (uncertain) age, one
should have expert advice. With our excellent
cardiac specialists easily on call, one should
not neglect periodically to have an electro-
cardiogram taken ; blood-pressure is not
enough. We must remember that this is an
age when deaths from heart disease have out- •
stripped deaths from tuberculosis. There must
be some reason for this. Why not find out
what that reason is?
But this paper remains what it at first in-
tended to be — a plea for exercise. The thera-
peutics of exercise have been told us so won-
derfully by Goldthwait, Camp, Garthwaite, and
many others. We do not need to answer the
advertisements of what Fishbein humorously
calls (yes, I said humorously !) “the big mus-
cle boys”. Their appeal is more for money
than health, just as so many Physical Culture
magazines are money getters chiefly through
their sex appeal lure.
Walter Camp’s daily dozen have been so
much disguised and distorted that not one in
a hundred readers can off-hand give them their
original names. Camp, however, did a great
work. It will live ! He stressed the avoid-
ance of strain, over-exertion, exhaustion. He
proclaimed a system that could be adapted to
the need and use of every one : little Willie and
Dad, young and old, even the sick or the well.
He also stressed the great benefit of the “rub
down”. He, time and again, stressed the val-
uable exhortation that it was not the spasmodic
use of his system, but its daily, long-continued
practice, a routine, — and that this only would
surely afford the promised good.
Collateral Reading
SANTA CLAUS AND NEW BOOKS
It has been our custom for some years past
to scan the book publishers’ lists in the late
autumn, to select those which seemed most
promising in the way of affording knowledge
and entertainment, and then to purchase such
as we most desired for personal reading and
for passing along in December as Christmas
gifts to friends. By that process we gained a
double joy from some books — the joy of read-
ing and the joy of giving — and made sure of
having some Christmas gifts, as it were,
through retention of such of the books as we
were too selfish to relinquish. Furthermore,
kind friends, knowing our weakness — we
might say double weakness, since our craving
for books is probably quite as much due to
a demand created by mental deficiency as it is
to love of reading and possession of books —
have usually on festive occasions presented us
with books.
The reading matter left here by Santa Claus
on his most recent visit is so varied in char-
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
145
acter and the books so numerous that we are
tempted to tell you just what is stacked upon
the table awaiting a chance to regale and in-
struct us during these long winter evenings.
The list of titles and authors includes :
Humanism as a Way of Life (J. George
Frederick)
Individualism, Old and New (John Dewey)
Pre-War America (Mark Sullivan)
Conquest of Happiness (Bertrand Russell)
The Lives of a Bengal Lancer (F. Yeats
Brown)
The American Leviathan (Beard and Beard)
Mrs. Grundy (Leo Markun)
Pauline; Favorite Sister of Napoleon (W. N.
C. Carlton)
Cakes and Ale (Somerset Maugham)
The Human Mind (Karl Meninger)
Fads, Frauds and Physicians (T. S. Harding)
Women and Monks (Kallinikov)
Soviet Russia (W. H. Chamberlin)
Enchanted Brittany (Amy Oakley)
Between River and Hills (Sisley Huddleston)
Roads to Roam (Hoffman Birney)
Our New Progress (James Bayard Clark)
Doctor and Patient (Francis W. Peabody)
f
What a feast in prospect! Philosophy, his-
tory, ethics, morals, romance, science, an at-
tack upon science, love and war, bolshevism,
American prosperity ( ?), travel, and the poetry
of a physician’s life. What more could one
ask? Where shall we begin with our reading?
In all probability we will express to you our
opinions concerning some of these books but
it is a duty first to dispose of one that has been
on our desk for some months, and we there-
fore offer the following review.
The Biologic Basis of Human Nature
H. S. Jennings
Professor of Zoology in the Johns Hopkins
University
(Reviewed by the Editor)
In his introduction to this book, Prof. Jen-
nings says : “Human individuals are diverse —
in their appearance, and in their behavior, and
each has a separate consciousness, a separate
identity ; so that the inward experience of any
one of them is a distinct thing from that of all
others. In some or all of these respects they
are typical of the material of biology.
How does it happen that individuals are thus
diverse, both outwardly and inwardly? Why
has my neighbor tastes and opinions so dif-
ferent from my own? Why does he conduct
himself in a manner that may seem to me un-
desirable ; a manner so diverse from that which
I would practice under the same conditions?
Why is one man fitted for one sort of work,
another for another sort ; and some for none
at all? Why do precise experiments in the
laboratory of psychology give with different
individuals diverse and incpnstant results?
Why are my own children so diverse from me
and from each other? What is it that makes
the behavior of human beings so incalculable,
inconsistent, astonishing? These are the most
practical , questions of life; and the most in-
teresting in theomy.”
Beginning with a detailed explanation, in
simple, easily understood language, of the
fundamental factors in the genesis of animal
life, he carries us through the biologic growth
of man, and discusses the effect and the limita-
tions of genetics practiced scientifically. To
indicate Dr. Jennings’ literary style and to give
you an indication of his method of dealing
with these important questions, we can do no
better than quote several pertinent paragraphs ;
at the same time advising you to read the en-
tire book.
“Characteristics do not fall into 2 mutually
exclusive classes, one hereditary, the other en-
vironmental. A given characteristic may be
altered by changing the genes ; and this is the
ground on which it is called hereditary. But
the same characteristic may be altered by
changing the environment ; and this is the
ground on which it is called environmental.
The genes supply one set of conditions for de-
velopment, the environment another set, and
there is no necessary difference in kind be-
tween them. The characteristic produced may
be changed by adequate alteration of either
set. From the nature of a distinctive charac-
teristic, it is not possible to decide whether it
is due to diversity of genes or to diversity of
environment, since the same peculiarity may be
due in different cases to either set of causes.
Which is more important for the charac-
teristics of organisms, heredity or environ-
ment? What is more important for the char-
acteristics of man? Which is. more important
for the manufacture of automobiles, tbe ma-
terials of which they are made or the method
of manufacture? This question is like the
other. No single general answer can be given
to either. For good results, both fit materials
and appropriate treatment of these materials
are required ; good genes and fit conditions for
their development. From materials of a par-
ticular sort, a good machine of one kind can
be made, not of another kind. A method of
manufacture that will fit one type of material
fails with another. Materials that are excel-
lent for one sort of machine are poor for an-
other; and the fittest of materials require
proper handling if their possibilities are to be
realized. Either poor materials or poor hand-
146
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
ling can ruin a machine or an organism. If
the materials are worthless, if the individual
starts with thoroughly poor genes, the method
of treatment, the environment, can do little.
And it the material is spoiled in the process of
development, it makes little difference what it
was at the beginning.
Most diseases are greatly influenced by the
conditions of life; yet most or all of them are
likewise influenced by the nature of the indi-
vidual's genetic constitution. For the occur-
rence of tuberculosis, infection with the tuber-
cle bacillus is required; and this is not a mat-
ter of genes, of heredity. But some combina-
tions of genes yield a much better culture me-
dium for the tubercle bacillus than do others.
A pei son that has such a gene combination is
much more likely to develop tuberculosis than
another whose genes do not yield a good cul-
ture medium for the bacillus. An “hereditary”
element is therefore involved. Yet the indi-
vidual whose genes produce a body that is
prone to tuberculosis need not develop the dis-
ease if he takes measures to prevent the bacil-
lus from getting a foothold in his body.
Doubtless there are many different types and
giades of individuals with respect to this mat-
ter. Some offer a particularly favorable
ground for the growth of the tubercle bacillus ;
others a less favorable ground, and so on
through a series of grades, till we reach indi-
viduals who are almost or quite immune to at-
tacks of the disease. The genetic constitution
is therefore of much importance in connec-
tion with tuberculosis. \ et the environment is
probably even more important. It is entirely
conceivable that by the discovery of measures
effective in preventing the transmission and
development of the bacillus, tuberculosis could
be brought to disappear ; so that genetic differ-
ences m susceptibility to it would be of no
further consequence.
. Similarly some combinations of genes yield
bodies that are much more prone than others
to break out into that unregulated growth that
is called cancer. In rats and mice, under the
usual conditions of existence, individuals hav-
ing certain sets of genes almost invariably de-
velop cancer, while those with other genes do
not. In other strains, with another set of
genes, about half the individuals develop can-
cer; in still other strains, none. These differ-
ences are inherited in Mendelian fashion,
showing that they are due to differences in 1
or 2 genes.
There are in these animals strains in which
a bit of grafted cancer tissue regularly devel-
ops into a cancer; others in which this almost
never occurs. There are strains that are par-
ticularly susceptible to one kind of cancer, not
to another. Many grades and qualities of sus-
ceptibility exist, up to that of individuals
derived from such combinations of genes that
they almost never develop cancer.
It is probable that in man there are similar
diversities in susceptibility to cancer, resulting
from the different genes of different individ-
uals. There is. however, no indication that
there exists in man strains having the extreme
susceptibility to cancer, shown by certain races
of mice. These extremely susceptible races of
mice are isolated and multiplied by careful sel-
ection and by breeding in such a way as to
bring together and preserve the gene combina-
tions that are most susceptible to cancer. This
does not occur in man, so that there is no rea-
son to suppose that there are any human be-
ings who are predestined to develop cancer,
whatever the conditions. The environmental
conditions that play a part in cancer are little
known; though it is known for rats and mice
that under certain conditions cancer is pro-
duced in individuals that under other condi-
tions would not suffer from it. It is conceiv-
able that knowledge and control of the envi-
ronmental factors for cancer (as for tuber-
culosis) should progress to such an extent that
the genetic factors would, in the case of man,
become of little importance.
A situation that is similar in principle to
that sketched for tuberculosis and cancer ex-
ists for most, if not all, diseases, infectious or
otherwise. Certain environmental conditions
are required for the occurrence of the disease;
or at least greatly influence it. But under con-
ditions favoring the disease, some combina-
tions ol genes yield to it, others do not. It is
probablg that there is no disease whatever,
acute or chronic, infectious or lion-infectious,
whose occurrence is not influenced by the na-
ture of the individual’s genetic constitution.
I here can be little doubt that, other things be-
ing equal, some genetic constitutions are more
readily attacked by plague, by small-pox, by
typhoid, by pneumonia, than others; just as
some combinations of genes yield more readily
to extremes of temperature, to exposure to the
elements or to unfit food; just as some gene
combinations are more likely than others to
come off victorious in v struggle with a wild-
cat, or to survive a bite from a rattlesnake.”
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
147
Lighthouse Observations
REHABILITATION of the disabled
Several original articles and discussion there-
of published in the December and January Jour-
nals, concerning industrial surgery and its rela-
tion to the Workmen's Compensation Act, re-
minded us of the recent work of the American
Medical Association’s Council on Physical Ther-
apy and the published recommendations hearing
upon physical therapy in the handling of injured
persons. Dr. Harry E. Mock, in a paper bear-
ing the above title — ^Rehabilitation of the Dis-
abled (Jour. A. M. A., 95: 31, July 5, 1930) — said:
During the last 2 or 3 decades a new era in
the practice of medicine has gradually developed.
Healing the burns and then leaving the patient
to his own devices to overcome scar contrac-
tures is not adequate treatment. The best pos-
sible reduction of a fractured leg and treatment
until solid union has occurred is poor surgery
if meanwhile the surgeon has paid no attention
to the protection of adjacent joints, has given
no consideration to maintaining muscle tone, and
fails to utilize those adjuncts of treatment which
will assure a rapid return to normal function of
the injured leg. Only by continued interest of
the physician in his patieftt during the long per-
iod of chronicity of the disease or injury, during
the long days of convalescence, even following
the patient back on the job to ascertain that
proper work is secured and making sure that
both his mental and physical restoration is as-
sured, can the ideals of physic logic medicine be
achieved.
The field and scope of rehabilitation of the
disabled lead the physician to consider many lay
adjuncts that heretofore have never been con-
sidered a part of medicine. To accomplish suc-
cessfully the rehabilitation of patients the pro-
fession must make contacts with these lay agen-
cies. Rehabilitation includes:
Prevention. (1) By analytic study of the disease
or accident to prevent a similar occurrence to
other individuals. (2) By treating the case in
such a manner that function will be preserved
in adjacent parts; that traumatic neuroses will
be combated from the start; that habits of idle-
ness and loafing will be prevented.
Every physician or surgeon engaged in private
or hospital practice secures information from
certain patients that shows a work hazard as
responsible for a given condition. A short let-
ter stating the facts to the responsible industry
will in most instances result in a correction of
the condition and therefore prevention of a sim-
ilar disease or accident. This type of preventive
work is just as essential as the reporting of con-
tagious diseases or of lead poisoning, yet how
few physicians think of this as a duty.
Treatment. (1) The best possible treatment di-
rected toward the earliest possible recovery with
the greatest possible functional restoration. (2)
Use of physical therapy as an aid in functional
preservation and restoration. (3) Use of occupa-
tional therapy to combat habits of idleness and
often for the purpose of training for new work.
To the surgeon interested in rehabilitation will
be referred many patients in dire need of recon-
structive surgery. Deformities and handicaps
must be corrected and function restored so far
as is humanly possible before the subsequent
steps of rehabilitation can be completed. This
is becoming so well recognized that state depart-
ments of vocational, reeducation for the disabled,
state compensation boards, schools interested in
the training and education of crippled children,
industries, and railroads and even private organ-
izations interested in the disabled are frequently
sending patients to such surgeons to ascertain
whether anything can be done to improve their
physical handicaps. Too often it is apparent that
if proper measures had been instituted during the
initial treatment this subsequent physical re-
habilitation would not have been necessary. De-
formities of the hands following tendon and nerve
injuries contribute largely to reconstructive sur-
gery. In many of these cases the original opera-
tions by the surgeon treating the initial injury
would have been successful if that surgeon had
been familiar with and had possessed the facil-
ities for administering proper physiotherapy.
Breaking up stiff joints by manipulation under^
anesthesia results in many permanent, bony an-
kyloses. The slower methods of physiotherapy
are far better. In a certain number of skull
fractures, the syndrome of persistent cerebral
contusion develops. Too often these sufferers
from indefinite symptoms are called malingerers
and are mishandled for months or even years;
making- up a pitiful class of the handicapped for
whom rehabilitation is very difficult.
No surgeon today is adequately equipped to
treat trauma cases who is not familiar with those
physiotherapy measures which will assist in the
restoration of function. It is not necessary for
him actually to administer the physical therapy
but he must know when massage and active ex-
ercise should start in every type of fracture;
when heat, massage and muscle training exer-
cises are indicated in nerve and tendon injuries;
when heat in the nature of diathermy is indi-
cated. Manufacturers of certain forms of ma-
chine therapy, for example, lights and electric
apparatus, have been active in advertising and
selling these agents to the profession until many
surgeons think that physiotherapy refers only to
such modalities. They have their uses in the
hands of physiotherapy specialists but are not
necessary for the simple physiotherapy proced-
ures that are required in 95% of trauma cases.
Convalescent care. (1) Early removal of the pa-
tient from hospitalizing influences. (2) Seeking
convalescent provisions for those whose home
conditions furnish unsuitable environment.
Provision for proper convalescence is the miss-
ing link in the chain for treating disabilities and
injuries. Think of the saving to industry and to
the hospitals if 25% of ward patients, after a
month or 6 weeks’ treatment-, could be trans-
ferred to a convalescent center where occupa-
tional therapy, physical therapy, outdoor exer-
cise and even vocational training could replace
the idleness, the reading of cheap novels, the
card games and the complaining about food and
nurses which make up the life of the average
ward patient in the average hospital.
Placement at suitable employment. (1) Light
occupations in the industry until such time as
the patient can return to his regular position.
(2) Choosing "a suitable job when disability pre-
vents return to his old position. (3) Develop-
ment of placement bureaus for the handicapped.
There are thousands of handicapped individ-
uals for whom employment is one of the gravest
problems of our times. This is not medical work,
yet if, as surgeons, we are aiming for an eco-
nomic end-result for our patients, it is one of the
most important steps in the rehabilitation pro-
148
lOl'RNAL OF THE MEDICAL SOCIETY CF NEW JERSEY
Feb., 1931
giarn and it is a movement which every medical
man should abet in every possible way.
Medical follow-up. We must develop our fol-
low-up clinics or office hours devoted to seeing
patients with permanent disability periodically
until assured that full functional restoration, so
far as is humanly possible, has been secured; that
the work they are doing is compatible with their
handicaps, and above all that the microbe of de-
pendence has not entered and undone all our ef-
forts to rehabilitate.
Message in Rehabilitation Work
In connection with the article above abstracted,
we would like to mention a special article by
Drs. Mock, Pemberton and Coulter (Jour. A. M.
A., 94:1989, June 21, 1930) covering in a de-
tailed and very thorough manner the use of mas-
sage and exercise in the treatment of injuries of
all sorts and in the follow-up rehabilitation work.
The article is too lengthy for satisfactory ab-
straction and -deserves to be read in its entirety.
Current Events
TRISTATE MEDK AI, CONFERENCE
The sixteenth session of the Tristate Medical
Conference was held at the Chelsea Hotel, Atlan-
tic City, Saturday, December 6, 1930, being called
to order at 10 a. m. by Dr. George N. J. Sommer,
of Trenton. Those in attendance were:
New 1 ork : Drs. William FI. Ross, Brentwood,
Long Island; James N. Vander Veer, Albany; and
Joseph S. Lawrence, Albany.
Pennsylvania: Drs. William T. Sharpless, West-
chester; Ross V. Patterson, Philadelphia; Walter
F. Donaldson, Pittsburgh; Frank C. Hammond,
Philadelphia; and A. C. Morgan, Philadelphia.
New Jersey: Drs. George N. J. Sommer, Tren-
ton; and FI. O. Reik, Atlantic City.
•Telegrams and letters of regret were read from
Drs. Sadlier, Trick, Mayer, Overton, Dougherty,
Donolioe and Conaway, who were unable to be
present.
Dr. Sommer : It is needless for me to welcome
you here to Atlantic City. The session will be
opened by Dr. Henry O. Reik, Executive Secretary
of the Medical Society of New Jersey, who will
read a paper, as scheduled upon the program.
Automobiles More Deadly Than War
Can We Control Their Death Rate?
Henry O. Reik, M.D.,
Atlantic City, N. J.
The subject which I am bringing to your atten-
tion may, I fear, have seemed to you upon receipt
of the preliminary program a queer one to pre-
sent for consideration by this conference. It
might better have been addressed to the general
public, but, if discussion of it and action upon it
meet with your approval it can be carried to the
public later much more forcibly. If you disap-
prove, and if mine be but “a voice crying in the
wilderness”, I shall at least have had the comfort
of crying aloud and of letting the world know
about my woes. In my opinion we are too calmly
watching a situation that disgraces civilization,
and for the past 5 years I have not only been
greatly agitated over existing conditions, but
amazed that there has not been an outcry con-
cerning the calamitous destruction of life that is
daily recorded.
In a country that claims to be the most en-
lightened and the most humane, we sacrifice hu-
man life to unrestricted pleasure on a scale that
was never before known and is even now scarcely
recognized by the majority of our people. And the
contrast between certain rules of our conduct is
almost unbelievable. We scathingly condemn bull-
lighting', and refuse to permit, in New Jersey at
least, even an exhibition performance (which ac-
tion I, of course, approve) lest 1 or 2 animals may
be tortured or killed. A considerable percentage
of our people, as may be witnessed in this very
city today, sets up a howl of protest against the
vaccination of dogs, designed to protect those ani-
mals and prevent the spread of rabies among hu-
man beings, on the score that a hypodermic in-
jection might discommode somebody's pet poodle.
And yet, almost without protest of any sort, we
read daily of the slaughter of innocents on our city
streets and country roads by that modern jugger-
naut— the automobile; an engine of destruction
that is excelled only by major implements of war-
fare. Human life seems to have become of so-
little value that we can read unperturbed about
murders and accidents that properly belong in the
category of murder.
On April 6, 1917, the United States of America
entered the World Wart On November 11, 1918,
the Armistice was signed. In that period of al-
most exactly 19 months this nation lost in action
3(1,931 soldiers, and the number of deaths occurring
later from the effects of wounds and diseases
brought our total loss up nearly to 50,000. The
average number of killed in war per month was
2100; the average number per day, 70. During the
year 1929, the number of deaths in the United
States caused by automobiles reached the total of
31,000, as against 28,000 recorded for 1928, and
the prediction on the first day of this month, De-
cember, was that the number of deaths due to au-
tomobile accidents will reach in 1930 the astound-
ing figure of 33.250. These last figures constitute
an average of 91 persons per day, as compared
with 70 per day killed in war. A community hav-
ing a population of 33,000 constitutes a city of the
first class, according to the census classification;
and we nonchalantly wipe out of existence such
a city each year. Worse than that shocking real-
ization, is the fact that an additional 1,000,000
persons are during the same year injured and more
or less permanently crippled by accidents in which
automobiles play the main part. Every 15 min-
utes throughout the day and night. 11 citizens are
injured by those deadly machines. Incidentally,
the property loss in damage from automobile
accidents amounts to approximately $700,-
000,000 annually. All of these figures have
been increasing at the rate of 10% per an-
num since 1920, and the end is not in sight.
It has been estimated that during the past 10 years
more than 150,000 American citizens have been
slain, and more than 5,000,000 injured by automo-
biles, embracing pleasure vehicles and trucks; a
death toll heavier that that of the worst was in
which we have ever engaged. For 10 years we
have been participating in peace conferences, war
prevention plans, naval reduction and disarma-
ment meetings — national and international — but
nobody pays anything more than momentary at-
tention to the horrors of automobile killings. We
erect monuments to the killed in war — though the
soldier had a ‘‘fighting chance”; but where is there
a monument to the automobile victims? Where is
the Kellogg pact that will conserve for us 33,000
Feb.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
149
lives yearly, and the Dawes plan that will save the
country $700,000,000 automobile wreckage annually?
Studying the above figures, is it any wonder
that the City Club of New York headed one of its
periodic Bulletins with the statement, in heavy
black type — “All Murder Records Broken; Motor
Vehicles in New YTork Streets Make Their Heaviest
Killing This Year!” It happened that the Bulle-
tin was devoted to a plea for additional play-
grounds and parks to keep children off the street,
and safely out of reach of the automobile, but the
automobile death toll is by no means limited to
children, nor even to careless pedestrians — the so-
called jay-walkers. The very article just referred
to stated that the proportion of children to adults
killed, out of the 950 deaths then under considera-
tion, was 386 children and 564 adults (practically
3 children to 5 adults); which is contrary to the
impression one gathers from general reading.
The only statistics I have seen, analyzing groups
of persons killed, stated ' that 60% of automobile
fatalities in the United States are caused by auto-
mobiles striking pedestrians, and only 20% are due
to the collision of machines; that the auto death
rate for females is only 35% of that of males; that
the age period between 5 and 9 years carries the
heaviest toll; and that between the ages of 4 and
65 the automobile is the most important cause of
accidental death. It is, of course, always a pathetic
occurrence when children are killed while engaged
in some outdoor game, but it is a matter of no
less importance that even a larger number of men
and women are killed during the rush hours of
traffic when they are returning home from their
day’s work; for it has been shown that the highest
percentage of accidents in the city occurs between
the hours of 5 and 6 p. m. As regards the expo-
sure of children to automobile accidents, Mr. D. S.
Beyer, Director of the National Safety Council,
made the following statement in an article on ac-
cident prevention; “As children, we may have
shuddered over the stories of persons maimed or
killed by wild animals, but on looking up the com-
parative figures, it is rather startling to learn that
while there were 2600 people killed in India in 1
year by wild animals, poisonous snakes, etc., there
were over 20,000 killed in this country by automo-
biles alone. Apparently, it would be safer for my
child to walk through the dangerous jungles of
Africa or of India than to cross the street in front
of her home.”
When we come to consider the character and
the causes of automobile accidents, we find a con-
fused state of affairs, largely because there has
been very little done in the way of thorough in-
vestigation of accidents. Very naturally, a death-
dealing accident is accompanied by a condition of
excitement and there is generally no one at hand
competent to investigate and study conditions thor-
oughly and without prejudice. Attention is apt to
be fixed upon ascertaining the person at fault, and
but scant attention is given then or later to con-
sideration of how and why the guilty party acted
as he did in producing the accident. We cannot
expect ever to have investigators on the ground
at the time of accident, but there might well be
some better provision for a later investigation of
conditions precedent to the event. Some thought
has been given to the sites most prolific of acci-
dents, to the character of the highway at the time,
to the existence of traffic signals, to the working
capacity of the cars, to the speed of the vehicle,
and to the sobriety of the driver; and the resulting
conclusions are more than surprising. For in-
stance: twice as many accidents are reported oc-
curing at the intersection of cross streets, as oc-
cur between those intersections — which would
seem to indicate that the jay-walker is justified in
crossing at the middle of the block. Most drivers
have their accidents in their own home towns,
where they are certainly more familiar with con-
ditions than they would be in strange territory,
which would seem to indicate gross carelessness;
80% of drivers accountable for accidents have had
their trouble in the town in which they lived. Of
all accidents reported, 58% have occurred in broad
day light ; 75% occurred on dry — -not wet — road-
ways; and the same percentage, 76, happened un-
der clear weather conditions. Less than 5% of all
accidents are the result of faulty mechanism of
the vehicles; the human machine is responsible for
95% of automobile accidents and few people seem
to have considered the importance of examining
the human part of the automobile driving ma-
chinery. Drunkenness or intoxication of the
driver has come in generally for a large share of
blame; a share which I am convinced has been
grossly exaggerated. I would not be understood
as excusing anyone for driving while under the in-
fluence of liquor, but I would suggest a more care-
ful investigation before denouncing a driver on
that score; because it is so easy for the by-stander
to mistake for a state of inebriety the mental con-
fusion and bewilderment of the shocked author
of an accident.
As to active causes of accident, exceeding the
speed limit, being on the wrong side of the
road, failing to signal the other car, passing street
cars or passing on the wrong side of other cars, all
have received a due share of recognition and con-
demnation. The one outstanding feature in the re-
sults of investigation may be summed up in the
very striking statement that in 75% of all acci-
dent cases the driver was “going straight through”.
I wish to emphasize that statement because I be-
lieve that in those figures we. shall find the most
important factor in the causation of automobile
deaths. Who are they among drivers that “go
straight through”, often, very often, regardless of
traffic signals and road signs? The speed maniac is
doubtless to be considered, but most observers have
arrived at the conclusion that speed of itself is
not the great source of peril it is presumed to
be; that it is speed in connection with other fac-
tors, such as negligence, recklessness and unfitness
to drive, that is dangerous. The Royal Commis-
sion on Transport, in Great Britain, has quite re-
cently recommended abolition of all limitations
upon speed, and that in the event of accident it
be considered only whether the driver was ex-
ceeding a speed reasonably adapted to conditions
then and there existing. The road hog certainly
must come in for a share of blame, but he con-
stitutes only a small percentage of all the drivers
associated with accidents.
I believe we shall find that the “straight through”,
dangerous driving, group is composed very largely
of persons who should never have been given a
license to drive; persons with bad eyes, bad ears,
bad feet, bad hearts, bad nerves and a poor qual-
ity of brain. In other words, I am personally con-
vinced that the great destruction of human life
annually produced by automobile accidents is due
in the main to the issuance of drivers’ licenses to
persons unfit to be entrusted with such responsi-
bilities.
Let us inquire under what conditions a license
to drive an automobile may be obtained. Only 20
out of our 48 states have any laws whatever gov-
erning the issuance of licenses to drive automo-
biles, and in those 20 states the laws vary greatly.
In all of those 20 states, and in the District of
150
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
Columbia, prospective drivers are required to show
a sufficient degree of literacy to justify the belief
that they can read road-signs. The only other
test of a preliminary character, in which those
states are in general agreement, consists of a
demonstration that the individual can start, guide,
turn and stop his car; for, though the tests leg-
ally required in those states would seem to call
for an adequate test of driving ability, the actual
tests are frequently so hastily and so carelessly
conducted that the examiner cannot possibly de-
termine the prospective driver s ability even to
handle the machine under the best of conditions.
A.s to any examination of physical fitness, there
seems to be no general agreement upon anything
more than a visual form test, and no suitable
provision for proper visual tests in any of those
states.
The 3 states with which we are concerned in this
conference stand among the most advanced in legal
requirements for licensing but even they leave
much to be desired. New York, Pennsylvania and
New Jersey motor vehicle licensing bodies require
applicants to pass examinations — oral in New York
and Pennsylvania, written in New Jersey — on the
rules of the road and knowledge of mechanism of
the car sufficient to enable the' applicant to oper-
ate it, and practical tests on the street “to start
and stop successfully, especially on a hill, and to
back up and turn around properly". The total
time devoted to such examinations averages 10
minutes for each applicant, divided into 5 minutes
for the oral or written examination and 5 minutes
for the practical demonstration. While an aver-
age of 25% of applicants fail on first examination,
the number of applicants ultimately refused li-
censes is well below 5%. Practically speaking, exe-
cution of the law has resolved itself into selling-
drivers’ licenses at fixed fees, varying in the dif-
ferent states from ,$l-$5, and annual renewal of
licenses amounts to exaction of one form of state
taxation. The so-called “Uniform Driver’s License
Act”, which is operative in all 3 of these states,
says that: "The Department shall examine every
applicant for an operator’s or chauffeur’s license,
before issuing any such license, as to his physical
and mental qualifications to operate a motor
vehicle in such manner as not to jeopardize the
safety of persons or property and as to whether
any facts exist which would bar the issue of a
license.” The law does not state of what these
examinations shall consist and, as already pointed
out, the examinations as ordinarily conducted are
in the nature of a farce. The law as it stands is
sufficiently broad to cover all that is required;
what is needed is better application and execution
of the existing laws. In each state the motor
vehicle commissioner has power to institute proper
and adequate forms of examination; what each
commissioner needs is a proper standard of ex-
amination to be established and put into opera-
tion, and, perhaps, some strong body of public
opinion to support him in the exactions of such
examinations. Herein, it seems to me, lies our op-
portunity for public service.
On this subject, the New York Times of Sunday.
January 5, 1930, in a very able article written by
Mr. Harry Tucker, Professor of Highway En-
gineering, North Carolina State College of Agri-
culture and Engineering, said: "Power and speed
are the features in the design of new automobiles
and trucks which some manufacturers emphasize
most in their advertisements; and power and speed
seem to be the most popular selling points with
automobile salesmen. Yet these powerful machines
are put into the hands of anyone who has strength
enough to hold a steering wheel and to push on
an accelerator. They are sent hurriedly along
crowded streets and highways at a greater veloc-
ity than closely supervised and carefully operated
railroad express trains. * * * * A number of states
now have laws requiring the licensing of drivers
of motor vehicles. If the requirements were car-
ried out strictly and only persons who are physi-
cally capable and mentally alert received licenses,
such laws would undoubtedly tend to reduce the
number of accidents. Unfortunately, in many cases
rigid examination is not given and a driver’s li-
cense is issued to anyone who has the required fee.
* * * * Practical laws, strictly enforced, would
certainly make automobile travel safer for all con-
cerned. And it would seem that traffic laws ought
to be uniform, since the automobile and good
roads have made us a nation of tourists. But, the
mere enactment of laws will not prevent motor
vehicle accidents.”
Is it our duty, as physicians, to take action upon
this question? I think it is. Who is in better posi-
tion than the physician to recognize the needs of
the situation and to offer the proper remedy? I
recall an editorial in the Rhode Island Medical
Journal of October 1924, which said in part: “Is it
not time for the medical profession to take an ac-
tive stand in a matter which so deeply concerns the
safety and welfare of the state — namely, in the in-
sistence upon more careful examination of appli-
cants for license to drive motor vehicles? This im-
portant matter is one in which physicians are con-
cerned not merely in the role of protectors of public
safety, but because a medical principle is involved,
that is, some medical examination of applicants
for license. Is it fair to have men and women li-
censed to drive automobiles who are color-blind,
who have serious defects of vision, who are feeble-
minded or suffering from mental disease?”
The Indiana Medical Journal carried a similar
editorial in November 1928, concluding with the
statements: “At present we permit the feeble-
minded, the poor-sighted, the crippled and the
underaged to drive over our city streets and coun-
try roads automobiles, everyone of which may be
considered high-powered and capable of making
high speed. However, it is not speed alone which
causes these misfits to have accidents. Instead of
establishing speed limits we ought to establish
ill iving tests and insist upon the examination of
every person who would drive an automobile.”
The New England Medical Journal of March 7,
1929, urging action by physicians, said: “Intelli-
gence, caution, courtesy and equilibrium, added to
good physical condition, are requisite to enable
one to operate an automobile with safety to him-
self and others. * * * * Has not the time come when
every applicant for a driver's license should pass
a physical examination, and be obliged to be again
examined after a period of years (for no one can
say that he will indefinitely remain physically fit) ?
Who can suggest these requirements better than
the physicians.”
The Literary Digest of July 23, 1927, carried an
article entitled “When the Auto Knows More Than
The Driver”, from which I have culled the follow-
ing: “Cars are now built for an intelligence that
their drivers do not possess; 50 mile an hour cars
are run by 20 mile an hour people; the public, 50%
of which is incompetent to drive a car at all — these
are the things that are making automobiles jug-
gernauts and our highways places of slaughter.
* * » ♦ when we look carefully at the world on
wheels we can find one great underlying cause
which seems to have been overlooked. The cause
is not in bad driving. No attention to signals, lack
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
of control, speeding — none of these so-called causes
are enough to explain it. Much deeper is the root
from which all these accidents spring — the unde-
veloped quality of consciousness at the wheel. The
drivers of automobiles are unfit, both in mentality
and application. The mass of people have had
automobiles thrust upon them before they are
qualified to use them.”
About one year ago, November, 26, 1929, to be
exact, the Newark Evening News published the
report of an inquiry conducted in 11 states by the
Traveler’s Insurance Company as to causes of
revocation of licenses. The greatest number of
cancelations and suspensions was made because of
intoxication, but the inquiry showed as a coinci-
dent discovery that the proportion of unfit drivers
is variously estimated by the State Motor Vehicle
Commissioners as between 10 and 15% of those
who are licensed; that physical defects are an
important feature in the rising growth of traffic
'disasters; and that 1 out of every 50 motorists
suffers from some bodily ailment which interferes
with his ability properly to operate a car.”
A similar study of the Personnel Research Fed- •
eration, reported in the Pittsburgh Press, March
23, 1930, shows that serious accidents are limited
to about 20% of all drivers and that many of these
are repeaters; that is, this 20% of operators is
responsible for 45% of all accidents. The question
is raised whether such repeaters can be cured, and
some experiments indicate that psychologic tests
of such persons and proper treatment of their de-
fects may convert a reasonable proportion of them
into safe drivers.
This review leads us to ask— what are the prin-
cipal physical defects that incapacitate one for
safe driving? Apparently, the majority of such de-
fects might be grouped under the general heading:
defects of vision, including color-blindness; deaf-
ness; crippled arms or legs; impaired hearts; un-
stable nerves; defective mentality. Some reasons
in support of this classification, taken from the
reports of accidents and gathered from observa-
tion, might readily be given. A few years ago one
of my patients, so near-sighted that even with
correcting glasses he could not possibly have seen
an object the size of a man at a distance of 500
yards, secured a driver’s license; and I think we
all know of drivers who have high degrees of
myopia or hypermetropia uncorrected. Consider
such a person as the patient I referred to and tell
me whether he should have been permitted to
drive. A car traveling 60 miles an hour (and that
rate of speed is not at all uncommon on our high-
ways) will cover 500 yards — 1500 feet — in less than
15 seconds. When that myopic friend realizes that
there is a man walking on the road in front of his
car, he and that man, both, must recognize the
fact, make up their respective minds what each
is going to do, and then do it, all in less than 15
seconds. If their minds happen to synchronize,
well and good, but, if they are out of harmony,
what chance has the pedestrian of escaping in-
jury? Or, suppose another car, traveling at the
same rate of speed and under guidance of a simi-
larly defective chauffeur, coming from the opposite
direction — is an accident avoidable? Another pa-
tient of mine, stone deaf from otosclerosis, holds a
license to drive. He cannot hear the traffic-cop’s
whistle nor the horn signal of a passing car. I
know it is customary to say that one depends less
upon his ears than his eyes when driving, but ex-
perience shows very clearly that a driver needs
all of his special senses to be functioning properly.
Some would, of course, put forth the argument that
an individual deprived of one sense, like hearing,
acquires increased sensitiveness of the other senses,
let us say of vision and touch, but I need scarcely
waste time with this audience in demolishing that
bit of hokum. As a third instance of physical de-
fect, I might cite the case of a licensed driver
who has one artificial arm, one artificial leg, and
according to her neighbors, a wooden head. She
can drive her car, but she has proved that she
cannot do so safely for she has had more than one
road accident; yet she continues a menace on the
highway. Regarding latent heart disease, epilepsy,
unstable nervous systems and defective minds, I
am sure you will agree with me that it is unwise
to turn such people loose with such dangerous,
high-powered instruments of destruction. Such
persons are endangering their own lives and the
lives of everybody they meet or pass upon the road.
How frequently do we read of deaths at the wheel
or immediately after leaving- the driver’s seat of a
car? Each report of that kind suggests the idea that
at least some accidents occur through the driver’s
having run amuck because he was suffering at
the moment an acute exacerbation of his heart
lesion. Nervous and mental elements are perhaps
less readily recognized but no physician will doubt
that accidents result from a driver’s not having
been able to coordinate his muscles properly at a
critical moment because his nervous system was
not functioning properly; his car may have been
“hitting on all 6” but his nerve apparatus or his
brain was 'missing fire”. It has been shown in 1
investigation that men over 50 years of age with
abnormal blood pressure had on the average more
than twice as many accidents as men of the same
ages whose blood pressure was normal. Even when
not so high as to indicate danger of sudden col-
lapse, high pressure may be a symptom of systemic
disease that affects the general health and tem-
perament to an extent that may seriously interfere
with safe driving. In all probability it is the true
cause of accident much more frequently than any
of us suspect. “Asleep at the wheel” is not at all
an uncommon explanation of accidents. Not very
long ago a prominent English surgeon, driving
home from a night operation that followed upon
a full day of professional labor, crashed his car
against a tree and was killed. He lived long
enough to pencil a note on his prescription pad:
“It was my fault — I was asleep at the wheel.”
Some of my friends tell me that often when driv-
ing long distances alone they become sleepy and
have to draw up beside the road for a short nap.
The intelligent driver will do that, but not all
drivers are intelligent, and many intelligent ones
will take a chance in trying to fight off the sleepy
feeling. I have even heard some reckless drivers
boast of having driven a car 'while asleep, which
makes me appreciate a witticism in the local
paper of 3 days ago, saying: “There was a time
when half-wits looked through bars instead of
windshields.”
The New York Evening Post, in an editorial
April 30, 1930, said: “A railroad management which
allowed an inexperienced man to drive a locomo-
tive would be regarded as criminal, and yet a
locomotive runs on rails and is regulated by a
system of signals, whereas on the highway the
driver of an automobile does his own regulating.
To allow a person to operate a car without having
proved his fitness and qualifications is simply to
invite accidents.”
This reference to railroads recalls to mind the
fact that 35 years ago we had this same fight for
conservation of human life, with regard to railroad
engineers. Some of you will possibly remember
how difficult it was to get rid of the color-blind
J 52
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
engineer. Accidents were frequent, people were
killed thereby, because the engineer could not
properly interpret the signals, could not always
definitely distinguish red, green, blue and amber
lights. Today no color-blind man can reach the
driver’s seat of an engine cab; he is disbarred be-
cause of his defective vision, and railroad accidents
have become rare. But on our highways and public
streets, If out of every 100 male automobile drivers
are color-blind, and 4 out of every 1000 female
drivers may be similarly classified. Realize what
that means in view of the fact that red and green
light signals are now being installed at street
and road crossings all over the country and that
safe driving depends very largely upon recognition
and proper interpretation of those lights. The
traffic-cops may not be aware of the fact but color-
blindness is the real reason why so many drivers
mistake the signal lights and cause him and them-
selves trouble even if no one else be injured by the
mistake.
What is to be done?
I hope I have made out a case showing the
necessity for reasonably strict physical examina-
tion of those who seek license to drive an automo-
bile. If I have succeeded, the next question con-
cerns determination of a standard for such ex-
aminations. In 1927, I requested the Welfare Com-
mittee of the Medical Society of New Jersey to
consider this question, and a special committee ap-
pointed to do so spent some months at the task
and on January 15, 1928, brought in a report which
embodied recommendations as to appropriate physi-
cal examination to be required as a preliminary to
receiving a driver’s license, as follows:
Questions to be Answered by Applicant for
Driver’s License
Note: The answers to these questions are partly
for the information of the examining physician.
Unfavorable answers will not necessarily result in
withholding a license.
1. Age?
2. Are you subject to: dizzy spells? fainting
attacks? fits or convulsions? pain around the heart?
3. Have you any serious disease of the heart
or the kidneys?
4. Have you every had epilepsy?
5. Have you ever had a stroke? or any form
of paralysis?
6. Have you any impairment of vision? Is it
corrected by glasses?
7. Have you any impairment of hearing?
8. Have you entirely free use of both arms?
hands? legs?
9. Have you been examined by a physician
during the past year? If so, give name and ad-
dress of the physician.
10. Are you physically and mentally capable of
operating a motor vehicle on the public highways?
I have read and understand these questions, and
the answers are true to the best of my knowledge
and belief.
(To be signed and sworn to after the physical
examination.)
Signature of applicant
Acknowledged under oath before me this day of
, 19
Notary Public.
Physical Examination
(Answers to be filled in by a physician)
1. Is there evidence of heart disease? If so.
what ?
2. Systolic blood pressure? (If applicant is over
50 years of age.)
3. Vision: right eye left eye
(Vision must be at feast 20 /50 in the better eye
and 20/200 in the poorer eye, with or without
glasses. If less than 20/200 in one eye, the better
eye must have at least 20/30 vision.)
4. Is the hearing good?
5. Has the applicant full use of both arms and
legs?
I certify that I have today examined
an applicant for a driver’s license, and consider
that he or she is physically and mentally fit
to operate a motor vehicle on the public highways.
M. D.
Date of license to practice medicine in New Jersey.
It will be noticed that the committee report
omitted any reference to color-blindness. That was
done because the committee feared that the color-
blind test would arouse so much opposition as to
endanger adoption of any physical examination. 1
thoroughly appreciate that point of view, but 1
do not agree that it carries sufficient weight to
justify the decision to put color-blindness aside. I
am personally inclined to add to the examination
form submitted a requirement for passage of the
color-blind test. Last winter I spent a Sunday
with a very distinguished attorney who lives in
New York City. Late in the afternoon, I requested
that a taxi be called to take me to the railroad
station, but my host courteously insisted upon driv-
ing me there himself in his own car. Rain was
not actually falling but the air was full of mist, a
light degree of fog. As we approached the first
corner on Fifth Avenue, my host interrupted our
conversation to say — “Will you please watch the
lights for me?” I was surprised at the request but
soon recovered my wits sufficiently well to recog-
nize the import of this question. Then he confessed
that he was color-blind, that on clear days he
managed fairly well to understand the light signals
but with fog or rain he was rendered more or
less helpless, and on such days was compelled to
rely upon watching the movement of other cars
in his neighborhood. Needless to say, I was con-
siderably relieved when he unloaded me at the
Pennsylvania Station. As a former practitioner
of ophthalmology, and as an interested observer of
automobile drivers, I am personally convinced that
color-blindness plays an important part in the
causation of road accidents. As Dr. Bulson pointed
out. in an editorial in the Indiana State Society
Journal: “It may be true that the color-blind in-
dividual with otherwise normal vision may dif-
ferentiate between “stop” and “go” lights by their
position rather than by their color, but such an in-
dividual is hopelessly lost if he drives in a strange
city or even in his own city where the relative
position of red and green lights may be varied from
time to time.”
I presume you are all familiar with the action
taken by the House of Delegates of the American
Medical Association at the recent meeting in De-
troit, calling upon our state societies to aid in
bringing about some form of physical examination
as precedent to licensing automobile drivers, and
submitting recommendations covering such an ex-
amination. I am perfectly willing to accept the
form of examination presented by the American
Medical Association, with the exception that, as
I stated with reference to the New Jersey Medical
Society recommendation, I would advocate insertion
of the color-blind test.
It matters not what physical examination re-
quirements we recommend, there will be objections
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
153
made against their adoption and application. The
color-blind, the near-sighte 1, the deaf, the epi-
leptics, the unfortunates with artificial limbs, will
each and all demand exemption. It may interest
you to know that one of our states now has a
special law that specifically forbids the motor
vehicle commissioner to refuse a driver’s license
to a deaf-mute. We all know, of course, how such
special legislation gets on the statute books, but
it is our duty to prevent such laws when we can
and, particularly, to recommend proper legislation
designed to safeguard public welfare and to effect
the greatest good to the greatest number. The ob-
jectors must be dealt with in the interest of the
larger number of citizens. On the whole, there
would be less objection than we may fear, and
such objection as will be made can be overcome
by presenting the public with the real facts.
My request of you today is, provided you accept
in principle my conclusions, that this Tristate
Conference shall recommend to our 3 state medical
societies such action as you may deem proper to-
ward securing uniform regulations governing phy-
sical examination of automobile drivers, preliminary
to the issuance of a driver’s license, and strict en-
forcement of such regulations. To that end, I am
offering a resolution for your consideration and
I trust that it may be adopted. In conclusion, I
would like to bring your minds back to a picture
of the results of an automobile killing and ask you
to remember that this picture, in only slightly
varied forms, has -been multiplied 33,000 times in
the United States during the past 12 months. The
picture was painted by the Philadelphia Citizen’s
Safety Committee and reads as follows:
“Think, Driver, Think/
A wave of the hand, a kiss blown on the breeze
— from the sweetest little pal in all the world.
I stood for some moments watching her, a
chubby little figure in blue and white, an extremely
important little person on her way to school.
And then she turned the corner.
It must have been about 4 o’clock — my mind has
been sort of deadened since — that the boss sent
for me. ‘Bob’, said he, laying his hand on my
shoulder, ‘there’s been an accident and you’d bet-
ter hurry up to the house’.
Well, there isn’t much more to tell. That little
pal of mine — she — she wasn’t at the window watch-
ing for me as usual. For an instant I faltered; it
just seemed as though something within me went
dead, and I had to fight for breath.
In a little time I went out to the gate, just as I
had that very morning. And I looked down the
street as best I could. Right over there, a short
block away, was where she turned the corner — :
passed forever out of my life.
Today, it was my little girl. Tomorrow, or next
day, it will be some other little pal quite as dear.
And so on, and on, until the conscience of men
shall cry a halt to this passion for fast driving in
localities where danger, obvious danger, stares
drivers plumb in the eye.’’
Gentlemen, lest yoh think this closing a bit melo-
dramatic, let me remind you that during the 45
minutes I have been occupied in reading this paper
to you, 3 American citizens have been killed, and
29,700 American citizens have been injured in auto-
mobile accidents.
Discussion
Dr. William H. Ross: One of the striking
thoughts that came to my mind after Dr. Reik
finished this rather impressive presentation was
that his remarks were followed by silence. Usually,
after any presentation so true and so striking as
this, applause follows. But today the profoundness
of the impression produced was so great that it
caused silence, and that is a very interesting fact.
Analyzing my own reaction, I was not at all in the
mood to applaud because the whole subject seem-
ed so serious. We have perhaps gotten into that
frame of mind because he brought home to us
the effect of things with which we are so familiar;
we know all these things and yet we just com-
placently go on. Frankly, I wondered just what
was going to be said, when this subject was an-
nounced, until a second thought brought home the
importance of it, but in no sense have I ever
grasped the great importance of the subject as I
do at this minute. Perhaps the situation is just
the same as it is in other things of life. The av-
erage person is subject to so many dangers that
he pays no attention to until he is hit on the
head. I should appreciate this situation as much
as any other human being because I have had to
bear the application of it to 2 members of my own
family who stand dearest and nearest to me, and
under the surface I carry a sorrow that I will
have all of my life.
There are some rather interesting things in this
connection. I have a niece, a deaf-mute, who has
a splendid mind. She graduated at the head of
her class in college and was signaled out and
given a diploma alone because they wanted to
say that she was the best loved individual in the
college. She is a librarian in a city, ■ and has a
license to drive a car and drives anywhere across
the state. She has never had an accident nor come
anywhere near one. It is an interesting reflection,
whether her intelligent mind keeps her from hav-
ing accidents or whether she is stimulated to more
closely observe the signals, but I would rather
ride with her than with some of my friends who
have no conception of their physical limitations.
However, there have been a sufficient number of
accidents and deaths to urge us, as the guardians
of health, to present effective arguments to the
authorities for correction. It is true, as the speaker
said, that the medical profession has an oppor-
tunity here for service and as the situation stands
at the present time we could present whatever we
have because we have facts to prove our conten-
tions.
Dr. Ross V. Patterson : I was very much inter-
ested in the subject and in the admirable presen-
tation of it by Dr. Reik. It is not a subject to
which I have given much thought but as he read
his paper a number of reflections came to me. The
paper is, of course, an argument for medical ex-
amination and I km in thorough accord with his
view that there should be such an examination.
It seems, to me, however, that we must recognize
that this would correct only a certain number of
the causes of accidents. The paper stresses medi-
cal defects as the cause of accidents. As medical
men I think we should be more restrained in urg-
ing medical examinations as being the solution of
the whole question; we should recognize the fact
that this is only a part solution.
Dr. Reik speaks of the large number of accidents
in this country. I wonder whether he can give us
any figures as to accidents in other countries and
the relative number of cars; whether there is a
disproportion of accidents to cars in use. The
reason we have such a large number of accidents
is because of our 120,000,000 population and 20,000,-
000 cars in the United States of America; more
than all the other countries in the world put to-
gether.
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
154
So far as Pennsylvania is concerned, we have
a motor vehicle law which states that there shall
not be more than 3 riders on the front seat, and
very frequently you will see 4, and the other day
on a street in Philadelphia I saw a little runabout
with 8 people in it. That was contrary to all rea-
son, of course, but for 6 or 7 blocks I trailed back
of the car and we passed 5 traffic officers who said
nothing about it. You will frequently see that sort
of thing at night.
I have always been impressed by instances of
automobiles driving into the city around 6 p. m.
to get the “head of the house”, having a small boy,
apparently under the legal age, driving the car with
a chauffeur sitting beside him. I have mentioned
that to the traffic officers and they have said that
sometimes the man has a greater political pull
than they have and they cannot lose the time to
go to the magistrate’s hearing and have therefore
passed it up. That is a potential source of danger,
of course.
The question of insurance is a very great feature
in automobile accidents. The insurance rates
are increasing each year. There are a num-
ber of automobile drivers who take the atti-
tude that the insurance companies will adjust
the accident no matter what happens, so they ig-
nore all the laws of common decency of traffic.
That seems to be a very large source of automobile
accidents today.
As to the question of being asleep at the wheel.
I think that occurs more frequently than we are
cognizant of. I remember, 2 years ago, going to
sleep at the wheel while driving up the Roosevelt
Boulevard. I found myself in the gutter twice and
finally pulled up along side the road, locked my-
self in the car and went to sleep. I had been
asleep about an hour when a park officer rattled
the door and asked why I had locked it. I told him
that I found myself going to sleep and I pulled
up to protect the public and locked the door to
protect myself. He saw the green cross on the
front of the car and said I would have to explain
this. I called up a friend of mine, explained thf
whole situation, and he said he would take care of
it for me. It was just a humilation, under the
circumstances, but I was trying to protect the
public by getting out of potential danger.
The question of “going through the red lights"
raised by Dr. Reik : we find that is a frequent oc-
currence in Philadelphia. At 33rd Street, especially.
1 have seen cars time and time again going through
the red signals. It is not particularly because the
drivers are color-blind but they are simply blind
to the lights. We had a very disastrous situation
in Pennsylvania recently. One of our surgeons
was on his way to Philadelphia to see a young girl
who had been operated upon and who was not
doing well. They telephoned the father to come
to Philadelphia to see his daughter. The father
was driving the car and beside him in the front
seat was the physician, Dr. Holden, who was Chief
Surgeon of the Locust Mountain Hospital. On
the rear seat was the girl’s mother and grand-
mother. Driving down the Highway, about 8.30
p. m., there was a truck stalled along the side of
the road. Whether there was a rear light on the
truck we do not know but there was a sudden
crash and the automobile drove head-on into the
rear of the truck. The doctor was instantly killed:
also, the father and the mother and grandmother
died shortly after reaching the hospital. Our feeling
is that the gentleman driving the car was talking
to the people in the back seat and his eyes were
not in front of him, and they were no doubt travel-
ing at a rapid rate of speed.
Regarding defects of hearing, I may speak per-
sonally. I find that while riding in an automobile
I can hear better than I can in a room and that
condition, of course, is well known to the medical
profession. However, I cannot hear very well at
times and must depend upon the officer’s whistle.
I was recently crossing one intersecting street in
Philadelphia and saw the officer put his hand up
to his mouth and then take it down, and I thought
he had blown his whistle, so started across. He
stopped me and “bawled me out”. He had intended
to blow his whistle but did not because he decided
to let a truck go through. I did not argue that I
had an impairment of hearing.
I understand there is a law in France regarding
pedestrians crossing the street, that frequently
they are arrested for walking into automobiles and
are fined when they are at fault. Very often acci-
dents are due to the carelessness of the pedestrians.
Week-end drivers also present a serious question.
So many factors have to be taken into considera-
tion. Those of us accustomed to driving on the
streets every day realize these factors. Many of
the dangerous drivers do not drive a. car at any
other time than on Sunday and have little ex-
perience.
There seems to be a marked tendency every-
where you drive for automobile drivers to demand
the right of way whether they are entitled to it
or not, which in many instances is responsible for
accidents, so that the careful driver is being penal-
ized to give the right of way on all occasions, in
order to play safe. The right of way seems to be
demanded in Pennsylvania to a greater extent than
ever, notwithstanding the fact that a few months
ago the Supreme Court of Pennsylvania issued
an opinion on the automobile law of the state to
the effect that the driver of an automobile has
right of way over another car coming to his left,
and that the car coming to his left cannot claim
the right of way by blowing his horn, or by the
fact that he arrived at the intersection first. It
would seem that many of the automobile drivers in
Pennsylvania do not know this ruling of our Su-
preme Court, because they persistently ignore the
question of right of way, or they are demanding
the right of way regardless.
I think Dr. Reik’s paper is excellent and T
sincerely trust that the resolution he has pre-
sented will be adopted. I think we should go on
record as to the feeling on the part of the medi-
cal profession in this regard.
Dr. A. C. Morgan : The reader of the paper
stated that 95% of the fault and responsibility for
accidents has been shown to lie in the human
element in driving, therefore this is an entirely
proper paper for presentation before this body for
our serious discussion. There are many laws on the
statute books now that are not being enforced. It
is proper that additional remedial legislation shall
be presented for consideration by our Legislatures
if these points are not already covered. The im-
portant point for us to consider is to find modes of
approach to impress upon these examiners of
motor vehicles of the 3 states the importance of
recognizing the fact that medical cooperation and
medical advice are paramount in value to the im-
position of rules and regulations upon those who
apply for registration. This would concern itself
in preparing questionnaires to be answered by the
applicants in writing, and perhaps requiring the
photograph of the applicant to be attached to
necessary papers. We should demand a statement
from the applicant in respect to fainting, epilepsy
Feb., 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
155
Another thing which Dr. Reik’s paper does not
stress, but a fact of which we are all aware, is the
carelessness of pedestrians; and I wonder if it
would be wise to urge that all pedestrians be given
a medical examination to determine their fitness
to be on the streets? Abroad this summer I travel-
ed 3000 miles in an automobile, in 4 different coun-
tries, and one of the things that very forcibly
struck me, particularly in England, was the
amount of road-courtesy as compared with our
own country, and I think that must be a very con-
siderable factor in lessening accidents in England
where the roads are narrow, tortuous, and where
there is no speed limit. There is the greatest
amount of road courtesy. The driver ahead, when
signaled, will instantly pull over. He will hold
out a hand to notify the individual behind him that
the road is not clear and he, being in front, can
see farther ahead, and will motion him to go ahead
when the road is clear and he can get by safely.
There is the greatest difference in our own coun-
try.
In Switzerland, as you doubtless know, they
enforce a different speed law on Sunday from that
of other days. During the week there seems t.o be
little regard to the speed which an automobile may
attain but on Sundays, when the road is crowded
with pedestrians, bicycles, and motorcycles, the
speed is rigidly cut down to 20 miles an hour.
Better enforcement of our laws, better education
of the pedestrian, are all parts of the problem and
as medical men we may contribute something, but
I should feel that we ought to be careful not to
claim that a physical examination, valuable though
it is, would be more than a partial solution of the
problem and in that view I am sure the author of
the paper will concur.
Dr. Vander Veer: This comes into my personal
knowledge with one experience. I have a relative
who drives a car but who has vision in only one
eye. She obtained her license after 2 examinations
but it was only the mechanical manipulation of
the car that troubled her. There is a very excel-
lent Examiner in Albany County who is in a meas-
ure economically free from pressure of politics. He
is a rather hard-boiled individual. He remarked
about her having no vision in one eye, as she- had
made that statement on her card of application.
However, she had sufficient corrected vision in the
other eye to pass the 20 foot card test given in
the street along the curbstone.
A man whom I attended as a patient in the Al-
bany Hospital somp 20 years ago, amputating his
leg, has a wooden leg and a contrivance on his car
so that he may work it. When he got out of the
car to take the examination he was told that he
had illegally driven his car down there and was
also told he could not pass the test because he had
a wooden leg. The examiner was invited to get
into the car and see the mechanical changes that
had been made to accommodate the wooden
leg, and the man was given a license. I have an-
other patient who is absolutely deaf, and who
passed the examination by reading the lips of the
examiner. I do not believe the examiner knows
that man is deaf.
I know one gentleman in Albany who is ap-
parently intelligent enough to fill a position in
the state service, who has had 3 accidents with
his car, once a very grave accident that had vis-
ible results by reason of his face being cut up. He
took 3 or 4 examinations before passing the test,
because he could not grasp the mechanics of the
car although he occupies a position requiring edu-
cational ability. His secretary, a very intelligent
woman, woke up one night in the ditch, having
fallen asleep while driving. Fortunately, she was
not going very fast and the car was upright. She
had a nonshatterable glass windshield, but the
wheel was broken in 3 places. Those are personal
experiences that have come within the range of my
knowledge.
There is no gainsaying the fact that we should
try to do something to better these conditions. The
National Association of Engineers saw the light
because it was put up to them in the proper way.
I am Vice-President of our Albany County Automo-
bile Club. The question of the modification of our
laws in the state of New York came up some years
ago and I was in a very marked minority in our
Executive Committee when I advocated a rather
harsh type of physical/ examination before the
person appeared for the mechanical examination.
The vote of the 15 members of the Board was 13
to 2 and as a result the State Automobile Associa-
tion turned the proposition down and it did not
get to the State Automobile Bureau. I know our
State Commissioner of the Automobile Bureau very
well and I also know his assistant commissioners.
They are rather in favor of this and yet the
pressure that is brought to bear on them by the
thousands of automobilists in the state and by the
County Automobile Association is great; so that
pressure- brought to bear upon them by the other
group does not get very far. A large number of
applicants are turned down at the first examina-
tion; most of these, however, because of the me-
chanical features; very few because of physical
defects.
Quite recently there has been a scandal going on
in New York State in that a number of people were
taking examinations for others, so that now for
a chauffeur’s examination one must present a pic-
ture of himself which is fastened to the card. We
have not been able to have it made obligatory that
each operator should have his picture on the ap-
plication blank and on his card in New York
State because political pressure has been brought
to bear and consequently we find scandals creeping
out here and there and as a result a number of
people who fail in one county go to another and
take the examination, and also other individuals
take the examination for them.
There is no gainsaying the fact that now seems
to be a proper time when we should determine some
complaints as to the automobile deaths and as
physicians try to obviate them even if in only this
one little point.
Dr. Frank C. Hammond: 1 think this is a very
timely subject that Dr. Reik has brought up for
discussion at this Conference and I do not know
any group more fitted than the medical men to
bring this matter before the Legislatures and I
hope the suggestion presented by Dr. Reik will be
adopted. It seems to me that this question brings
up so many angles for discussion: first and pri-
marily, the question of the traffic officers enforcing
the law. We have so many laws that are not en-
forced and if they were enforced to a greater ex-
tent a great many conditions might be overcome.
Those who drive automobiles on the street every
day are conscious of the fact that traffic officers do
not enforce the law. I have taken this matter up with
some traffic officers and they say that when they
report any one to the City Hall in Philadelphia
they are compelled to appear before the magis-
trate at 7 o’clock in the morning, the magistrate
not arriving until 8 or 9 o’clock, and they have
to lose that time to be present at the hearing and
for that reason frequently do not report infringe-
ments of the law.
156
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
and previous accidents sustained, occupation and
perhaps other facts.
Dr. Reik emphasized the fact that most accidents
occur between 5 and 6 p. m. That bears out the
study being carried on in this country particularly,
and in other countries, in regard to the accidents
in mines, in mills, on the streets and the occurrence
of falls. For a few years past I have been inter-
ested in the subject of falls and their causes and
their application to the medical profession. That,
of course, is from a medical internist’s standpoint,
and yet I feel that it has a very valuable bearing
on this subject before the house today. There are
some people who tire very easily, mentally and
physically, making them relatively unsafe to drive
their cars or to have any responsibility that in-
curs the possibility of danger to other people. This
is a strictly medical and properly a medical phase
of the subject that can be discussed with the State
Commissioners of Vehicles. Dr. Hoffman, the
eminent statistician, is carrying on some very valu-
able work along this line.
There is a very important point for us to con-
sider as medical men, and that is to have unanimity
as to what constitutes intoxication. We will find
definitions quite variable, and likewise the testi-
mony of the man who examines an individual and
pronounces him drunk today may be changed after
he sleeps over it and has a telephone call or a
visit from a politician, as I have had reason to
experience as one who made charges and then had
the medical man reverse himself the next day in
what I considered to be a wanton case of drunken-
ness.
Epilepsy is another feature that should be
stressed. I know of a very eminent physician
who while driving along the River Valley in New
York suddenly wakened in a little ravine; his wife
was dead, his boy escaped injury, and the father
was so crippled that he could not get out of the
car. The little boy had presence of mind to run
back to a small place and summon help. This sad
accident was not explained satisfactorily for 2
years, when the doctor eventually died of a brain
tumor. He had a sudden faintness and loss of con-
sciousness because of the beginning pressure of
that brain tumor. Autopsy revealed the presence
of this brain tumor and then in retrospect the
cause of that accident w'as made clear.
The matter of blood pressure should be em-
phasized again by us in discussion of all periodic
health examinations, particularly the marked im-
portance of hypotension. A man with hypotension
is, theoretically at least, potentially more likely to
develop fainting than a man with hypertension. The
man with hypertension is more likely to have fits
of anger and disturbance of equilibrium and mental
poise, and both phases of this blood pressure ques-
tion are questions to discuss in respect to the abil-
ity of a man to drive a car.
Another important thing: It is proper to require
an examination for fitness at the time that one
makes an application, but there should be as a
medical requirement a demand that every 3 to 5
years when the applicant applies for re-license he
shall likewise be subject to a reexamination, be-
cause physical alterations do occur and might
greatly influence a man’s fitness as a driver. Those
of you who have reached the age of 60 will recall
that in your insurance policies at the age of 60
your rate of premium is greatly increased. It is
rather astounding and rather jarring to have that
fact made known, that the insurance carriers real-
ize this and raise the premium of those who are
carrying accident insurance after the age of 60.
This is a proper thing for discussion in putting
this phase of the problem before the Commission-
ers of Vehicles for their legislation.
A year ago an engine driver was taken from one
of the speed trains leading into Atlantic City. His
brother before him was a cardiac case and had
dropped dead on the street. This man was ex-
actly the same age as his brother had been when
lie died. He went up for a physical examination
before the railroad medical officials and was taken
off the speed line and put on a shifting engine in
one of the railroad yards. This man had a slight
accident and was taken off that job and simply used
as a guide or flagman. The patient was referred
to me and my opinion was expressed that he was
not a safe man to drive an engine. A couple of
months ago I learned that with political pull in a
certain part of New Jersey that man is back on a
shifting engine in the yard. I shall be interested
in the further progress "of that case. It is proper
for us to study as medical men the occurrence of
previous accidents so that the answer to Dr. Reik’s
question as to why the person was at fault, why
that accident occurred, should be settled not from
the line of mechanics alone, which has to do with
brakes, with laws, etc., but also with respect to
the physical and mental condition of the individual
at the wheel.
There are many points that occur to me but I
feel that they can be better discussed in round
table conference, but I am strongly convinced that
our easiest, shortest and best way to approach
this subject for the present is to get in touch with
the Examiners of Vehicles; if you please, give
them transcripts of our meeting here today, have
them put in reprint form so that the Commission-
ers, the heads of departments, members of Boards
in the respective states shall be given the printed
suggestions, and later ask for a conference. Or,
put them in the hands of the family physicians and
reach these men as men rather than officials, and
I think we will accomplish more good for the people
of our commonwealths in a shorter time than by
resorting to legislation which, as you know, it re-
quires many years to accomplish.
Dr. Joseph S. Lawrence: I want to add my ex-
pression of appreciation of this splendid paper that
Dr. Reik has given us on a very timely subject.
We are the proper persons to give consideration
to this subject, I believe, and the proper group to
initiate some further consideration of it on the part
of the public because we are the ones who are al-
ways called in to salvage the wreckage of the
human side of it. Dr. Reik gave such evidence of
admirable study of the subject that I hesitate to
make any suggestions with regard to the points
that he did not mention for fear that he considered
them of minor importance, but from my own per-
sonal experience in a near-accident I cannot help
but mention that a certain proportion of these
accidents are due, as has been stated by each of
the speakers, to a weakness on the part of the
pedestrian. About a year ago I came within close
proximity to running down, or killing, a child about
4 years old. About 6 o’clock in the evening I was
driving at not more than 25 miles an hour when
I saw a child on the curb who apparently saw me.
When within 2 cars’ length, suddenly the child ran
out in front of my car. I was fortunately able to
turn the car across the street without upsetting it,
and escaped the child.
I also think of another factor, which was men-
tioned once, and that is the condition of some cars
that are out on the roads. We have, of course,
our efforts at checking up on the brakes, etc., but
even if right one day they may not be right the
next day. Many people do take liberties on
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
157
account of the confidence they have after having
had their brakes checked and they keep the slips
on their windshield often for 6 months to show
that their brakes were examined.
With regard to the correction of some of these
difficulties, it is a question whether we could get
legislation for 5 years and maybe 10 years. At
any rate, it is a question whether we could do it
without the full hearted cooperation of the auto-
mobile associations of our several states and of
the national one. 1 have found in my experience
with the Legislature in New York that when mat-
ters relating to automobiles, and even certain con-
ditions of the highway, are under consideration the
opinion of the Automobile Association is very in-
fluential. They attend hearings in large masses
and usually have as their representatives influen-
tial persons, and I believe that whatever we do
we must seek the cooperation of the Automobile
Associations.
Now, I wonder if we would not make more rapid
progress if, instead of an extensive examination
such as suggested, we simply asked for inclusion
in the examination that is now given of one or
two more particulars. For instance, I am very
much impressed by what Dr. Reik has said about
color-blindness. If a certain percentage of the
men are color-blind and they are in a hurry to
make time, a red light would mean nothing to
them and they would be the ones whc would pass
the red lights, especially in strange communities.
However, it was pointed out that the majority of
accidents occur in one’s home community, and
that is true in all accident experiences. I sold acci-
dent insurance at one time and the most frequent
place of accidents was one’s own home; the most
intelligent person, the minister or doctor, was sure
to fall over his own doorstep. I think if we could
secure inclusion in the examination of the test
for color-blindness, or the eyesight test, and also
the exceedingly evident condition of epilepsy, it
would be a good thing to accomplish. Those 2
conditions can always be proved as existing. If
we could add these 2 conditions, which could not
be changed, and in time add 2 or 3 more, this could
be done with comparative ease I believe.
Dr. William T. Sharpless: I think this discussion
is very timely and Dr. Reik's paper has made a
very deep impression upon us. My feeling is that
while there are a great many matters that might
be corrected by a physical examination, from my
own observation a great many accidents have
occurred from wilful disregard of the signals. That
is not because of color-blindness or inability to use
either hands or legs, nor because of any sort of
physical defect, but simply because they wilfully
disregard signals. It is just a part of the sheer
disregard of law that is so common in all classes
of society at present.
Dr. Morgan spoke of the shock that he got when
he learned t Hat at the age of GO his rate for acci-
dent insurance would be increased. Wait until h<j
comes to be 70 and he will have no accident in-
surance at all.
I think those objecting to this law would not be
the people who are driving cars, so much as the
people who are selling and manufacturing cars,
because the restriction of those driving would cer-
tainly restrict the sale of cars and I believe we
would have some difficulty from that source. Again,
they would say that the doctors are working up
something for their .own benefit, that they are in-
creasing work for themselves and are not so much
interested in the protection of the public as in
their own benefit; some people are evil-minded
enough to do that.
I know a man, a doctor, who had the full use of
his faculties, and of his arms and legs, who wets
run down by a trolley car and his arm so injured
that it had to be amputated at the shoulder. He
had had accidents previous to that but since his
arm was amputated he has had no further acci-
dents, perhaps because it has taught him a lesson
and he is now more careful. Previously his care-
lessness had killed that very efficiency which
should have been a safeguard against accidents.
Dr. Walter i\ Donaldson: I do not believe there
is any point of this discussion that has not been
touched upon either by the essayist or those tak-
ing part in the discussion, but no one has yet said
that it should be accentuated that when drivers
approach crossing^, feeling confident that they
have the right of way, they should always stop
long enough to ponder that possibly the other man,
coming in the other direction, does not realize that
he has not the right of way. In other words, we
should not consider that we have the right of way
or will receive the right of way. I was driven 90
miles within 70 minutes by a very good chauffeur
recently and I am sure that we covered that dis-
tance in absolute safety because this driver, al-
though he had no speed limit, yet when he saw
a vehicle or a pedestrian was much more careful
to slow down before any accident could possibly
happen.
I am in perfect sympathy with what Dr. Reik
has said to us today and I am sure that his paper
once within our possession in printed form will
become a matter of reference for many years, just
as a paper of Dr. Ross’ prepared for this confer-
ence has taken that position, and I am perfectly
willing to go back to my State Society and help
to bring about this ideal situation. I know that
Dr. Reik does not expect that we will accomplish
much immediately but I am sure that it is our duty
to keep driving away on this point because no one
else will do it, and no one will expect more physical
restrictions to be put upon this thing than the
doctors of the state think should be put upon it.
I am in favor of putting it on a bit heavy with
the hope that 35 or 40% may be accepted, and we
might be well satisfied for that year. We probably
represent 35,000 practicing physicians and 35,000
motorists and we might urge our own motorists to
become practitioners of the Golden Rule. Common
courtesy of the road cannot come to a boy or to a
foreigner or to an individual whd has not had
the good fortune to have lived in the days before
automobiles became so common and when people
did know and practice ordinary vehicular road
courtesy. Unless a person has had that good for-
tune, then somebody else must teach it to him.
We cannot expect a foreigner to our shores who
has been here but a few years, and never before
dreamed' of the day that he would be able to own
even a wheelbarrow, suddenly put into possession
of this tremendous engine of destruction — we can-
not expect him to look out for the niceties of driv-
ing unless he has a mighty good example set to
him and has the force of the law occasionally
brought to his attention.
Motion. I herewith move that this resolution as
proposed by Dr. Reik be adopted.
Dr. George N. J. Sommer: My reflections are
from the standpoint of the visiting surgeon of a
hospital and what occurs in our immediate neigh-
borhood, at Trenton, in the way of major accidents.
We have 2 very dangerous zones. One is Langhorn
and the other lies about Bordentown. in New Jer-
sey, on the direct line to New York. As you know.
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
158
there has been built a new direct highway to New
York which shortens the time of travel very ma-
terially. It is a 3 lane highway. A big truck wlil
sometimes stop on 1 of those lanes and at once
you have set a scene for a tragedy, which often
occurs. Quite recently a prominent surgeon was on
his way home, Thanksgiving Evening, and a car
was going through Trenton with some prominent
people in it who were going at a pretty good rate of
speed. A big truck was standing, or moving slowly,
in one of the lanes. I do not know whether an-
other car was occupying the third lane but the car
that tried to pass, in trying to avoid the other car,
collided. The doctor was instantly killed, and the
wife, son and daughter injured; the occupants of
the other car suffered a fractured arm, a fractured
leg and sundry cuts and damages; the chauffeur
had some scalp wounds plus a few broken ribs.
Now, that is one of the dangers of the sectional
highways over which there is a tremendous lot of
traffic. I can testify to what dangerous things
these large trucks are. Quite often you will find
them parked alongside the road, and their signal
lights are under the car and are hard to see. I
noticed recently that some of them have several
lights on the rear now and 3 or 4 in the front, but
the average truck is a huge menace to the mo.tor-
ist and they are all terribly fearful of the presence
of these large trucks, so that a 3 lane highway
introduces now a new problem in road building.
There will have to be 4 lanes, or highways in only
1 direction, in order to avoid 1 great element of
danger in road traffic.
As to the question of epilepsy, a friend of mine
went South about a year ago with a chauffeur. It
happened that they took a physician along also.
They had several near accidents and then it was
discovered that this man had minor epilepsy and
at times had suffered with temporary lapses of
consciousness. Another friend was crossing the
Five Points, in Trenton, where there is a silent
policeman in the center. At 1 o’clock in the morn-
ing he went head-on into that signal. It developed
that he had previously had a number of seizures.
Not long ago a traffic officer called my attention
to the fact that my chauffeur had passed the signal
several times. He is about 60 years old and I
found that he had retinal hemorrhages.
Certainly these suggestions that examination
should be made every few years are good because
many conditions arise in the course of 5 years
that might convert one from a safe into a danger-
ous automobile driver. I am in sympathy with the
step that drivers should be known to be in good
health and not a direct menace in so far as their
physical health is concerned. In regard to their
ideas of road courtesy and politeness, as I see it,
there is not any courtesy or politeness in the minds
of most automobile drivers. All they think about
is to blow their horns and get you out of the road,
having not even a reasonable doubt in mind that
you may not be doing something sensible for him.
Dr. Henry O. Reik (Closing): I am very grateful
for the free discussion of my paper. Regarding the
various defects that I have mentioned, and some
Dr. Ross has cited, particularly the deaf-mute who
is an exceedingly capable driver, I want to make
it clear that while I referred sarcastically to that
special bit of legislation, I did not mean to imply
that the privilege of driving should always be
refused because of deafmutism, but that I did not
approve of giving them a license because of deaf-
mutism. Then, as to deafness, I would far rather
ride with Dr. Hammond, handicapped as he is.
than to ride with a man having perfect hearing but
an imperfect sense of responsibilities.
Dr. Patterson spoke of the discourtesy of the
road. I also happened this past year to have done
a good deal of riding in England, Ireland, Wales
and France The courtesy of the road in England
is one of the most striking things one notices. In
France the situation is somewhat peculiar. Of
course I have heard a great many complaints in
every city of the taxi-cab drivers and bus drivers
but my observation has led me to believe that, as
a class, they are about the safest drivers we have
to deal with. In France, that is particularly true.
The French taxi-cab driver is about the best one-
hand driver in the world ; whereas I found that
private citizens did all sorts of things that were in
violation of the law. The French have no speed
limit but have very strict laws and immediate
punishment if you have an accident. In France,
on the general highways the courtesy extended by
drivers of public vehicles is very marked, but it
is just as marked that the private citizens extend
no courtesy to one another. I think they are about
the worst lot of drivers I have ever encountered. I
traveled on many buses in Brittany this summer
and these drivers were always ready to give way
to another vehicle, but the private driver was
hogging the road whenever he could.
As to the relative proportion of accidents com-
pared to the number of cars, it is said to hold good
that there is about a relative proportion of acci-
dents in the various countries, so that it would
seem that it deals very largely with the human
factor in driving cars. The only country in which
there is strict physical examination — and it has
had a bearing on the prevention or reduction of
accidents — is Holland.
Dr. Lawrence misunderstood me in thinking
that I was suggesting any new legislation. I said
that in these 3 states I believe there is no extra
legislation necessary. The motor licensing bodies
are clothed at present with sufficient power but
what they need is moral support. They are afraid
of the great number of defectives, the automobile
clubs, and more particularly of the automobile sales-
men who do not want anything to restrict their
possible number of sales.
My feeling is that Dr. Lawrence. Dr. Morgan
and Dr. Hammond have all urged just what I
meant to say in my paper, that the thing to do in
each state is to brjng our influence to hear upon
the Commissioner of Motor Vehicles. He has at
hand sufficient law at present to put these things
into force. As to what the character of the phvsi-
cal examination should be, this plan was sug-
gested by a committee in our Society and was
drawn up as the simplest applicable form. We
tried to avoid the charge that we were trying to
make business for ourselves. Of course, if it calls
for physical examinations it will indirectly make
business for some doctors but we do not want to
ask to have physicians at these bureaus to make
the examination.
I have no notion Dr. Patterson, that this would
prevent all automobile accidents but I do think it
would prevent a goodly number. Persons will still
do foolish things on the road, will wilfully disre-
gard lights, etc., which we cannot prevent but we
can contribute something. Statistics seem to show.
Dr. Lawrence, that defective machines account for
only 5% of the accidents: I suspect there must be
a larger proportion than that, but those are the
statistics gathered at the time or immediately after
accidents, and of course at such time each man
will swear that his machine was in perfect order,
and often you cannot tell after the wreck whether
the car was previously in good condition or not.
But when you realize the number of second-hand
cars that are sold and the number of defective
Feb.. 1 9,31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
159
ones turned in, for exchange, there must be a large
number of cars on the road that are not really in
good condition.
Regarding the 60 year . age as to accident in-
surance, I am one of the unfortunate victims. I
carried an accident and health insurance for 35
years and on my sixtieth birthday received a notice
that I would have to pay a very heavy premium
if I wanted to continue to carry any insurance. In
New Jersey the State Medical Society has made
a group contract arrangement for health and acci-
dent insurance and any member of the society can
take out an accident and health policy through the
society without regard to his age. So I invite you
to come over into Jersey and join our society.
As to claiming the right of way, I think that is
one of the most frequent causes of accident. Some
people think that after they have blown their horn
all the rest of the world should stand idle and let
them drive on. Dr. Sommer referred to some of
our Jersey roads and I would mention the White
Horse Pike. If any of you want to make money
you can safely bet that there will be 2 people
killed tomorrow (Sunday) down there between
Philadelphia and Atlantic City. That is the av-
erage Sunday rate for the past 3 years.
I have been collecting information on this mat-
ter for the past 5 years. I culled out of it the strik-
ing things, and of' course, I have only presented
one aspect of the picture. I presented it, as I am
accustomed to do, rather forcibly because that was
the thing I wanted to get before you. What I did
ask was that we might adopt a resolution that we
should take back to our respective societies, a
recommendation that they each do something to-
ward eliminating this large number of accidents.
It was one of the objects of this conference in
the beginning that we should try to bring about
correction of some of these evils, especially legis-
lative matters, and that we should try to have uni-
fied action, and I thought this was one of the sub-
jects that we could act on with harmony. Whether
we should recommend this physical form of medi-
cal examination or the one set forth by the Ameri-
can Medical Association is of no great importance.
I think either would have to be modified for each
state in order to get it adopted.
Dr. Sommer: Before I put this resolution before
you I might say that we are much interested in
New Jersey in the control of accidents because we
are such a big interchange highway between the
points East and West. There is a tremendous
amount of traffic over our highways and they are
being extended more and more all the time. We
are getting ready to spend another $100,000,000 on
them, and it is quite important that our highways
shall be made as safe as possible. In our county,
Mercer, we have had as many as 12 dead brought
into 1 hospital in 1 week. Our hospitals on Monday
mornings are filled with automobilists broken up
into various pieces.
Motion previously made by Dr. Donaldson, that
the Resolution presented by Dr. Reik be adopted,
was seconded and unanimously carried.
Resolution on Physical Examination of
Automobile Drivers
Whereas, the number of deaths resulting from
automobile accidents in the United States of
America has reached the enormous total of 33,000
for the year 1930, and continues to increase an-
nually at the rate of 10%; and
Whereas, it seems apparent to physicians that
a very considerable proportion of this terrible death
rate is due to the unfitness of many automobile
drivers ; and
Whereas, we believe that every applicant for
an automobile driver’s license should be required
first to show physical and mental fitness to be en-
trusted with the handling of a machine that car-
ries so many possibilities of dealing out death to
innocent citizens; and
Whereas, the requirements of such a physical
and mental examination as a preliminary to the
procurement of a license is within the power of
motor vehicle commissioners to institute, without
working a hardship upon anybody who has a
reasonably good claim to possession of a driver’s
license;
Be It Resolved, that the Tristate Medical Con-
ference recommend to the Medical Societies of
New York, Pennsylvania and New Jersey the
adoption of a standardized jilan for such examina-
tions, and request that each society use its best
endeavors to procure in its own state a legal re-
quirement of such examinations precedent to
issuance of drivers’ licenses.
Obligations of Professional Public Medical Service
William H. Ross, M.D..
Brentwood, L. I.
While medicine’s interpretation of its problems
is largely economic, there is a growing appreciation
of the value of medical public relations. There are
many health influences at work today with the ob-
jective of improving public medical service. These
organizations need guidance and leadership and it
would be better for the profession to furnish them
leadership in the interest of both the public and
the profession, than to let them go on without
guidance.
Reduced to essentials, the real problems of
medicine are: first, to increase public availability
of medical resources for preventing disease and
conserving health; second, provision for adequate
medical care for every citizen of the state at a
price that he can afford to pay. These are import-
ant problems that will press harder and harder for
solution.
While the profession of medicine is attending
to its private occupation of the practice of medi-
cine and fulfilling the desired relationship of doc-
tor and patient, it should meet its public service
obligation and give guidance to the solution of
social medical problems that command more and
more the support of intelligent public opinion.
Medicine could do this better during the formative
stage of health activities than after these have be-
come established. For its own protection, medicine
should take a more active part in the solution of
public medical service problems. It is generally
accepted that a primary function of government
is protection of the health of its people. Other
countries have assumed, in varying degree, this
responsibility. It would be better if the profession
in America would work out a system to take care
of public health problems rather than to wait
until other organizations assume the responsibility.
We should remember that medicine has always
been a social function. It is only 200 years since
it depended upon gratuities. The profession ren-
ders its services in time of distress and disaster.
Medicine has a very definite relation to the reali-
ties of life. In this sense the medical profession
sustains a different relationship than any other, but
it is not organized for the administration of public
medical needs. It requires the help of other or-
ganizations and some of them are governmental.
Medicine, however, is looked to by the public to
160
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
direct and furnish leadership to all of these activi-
ties. These things will not be settled by any wisdom
of the present, but by a vision of the future. What
will be the social conditions confronting medicine
if there is a further development of the use of
machinery in industry? What would happen if
man’s wants could be supplied without giving an
occupation to everyone?
In studying the problems of medical relation-
ships, the view point of the general practitioner is
probably the nearest correct. The general prac-
titioner makes up 80% of members of the profes-
sion of medicine, and general practitioners do
80% of the practice of medicine. In working out
the problems of medical relationships, it is neces-
sary to understand the view point of the public on
one hand, and, on the other, the view point of the
practitioner of medicine. There is a responsibility
resting on the medical profession to improve public
medical relations. It is apparent that the public
expects the direction of public health service by
doctors and that the public looks to the medical
profession to make available the resources of
health agencies, official or unofficial, and to give
them professional leadership. It is apparent that
•the public expects the medical profession to de-
termine the soundness of health programs. The
profession of medicine should carefully meet pub-
lic expectation before the public turns to other
sources.
Organized medicine, through the Public Rela-
tions Committee, in New York State, is under-
taking to constructively solve unsolved health and
medical problems instead of destructively contend-
ing with the efforts of the public assisted by un-
official agencies. The Public Relations Committee
is broadening the view point of medicine. It is up-
holding the work of the general practitioner and
making him more interested in the broader prac-
tice of medieine. It is undertaking to find the
common ground upon which medicine and other
organizations can work for the betterment of pub-
lic health, instead of objecting to programs on the
sole ground that, they interfere with the private
practice of medicine. The Public Relations Com-
mittee of New York State is endeavoring to develop
conditions inimical to the oncoming drift of state
medicine. If socialized medicine ever comes in
America, it should not be because of neglect on
the part of the profession to meet public medical
problems.
Discussion
Or. Patterson : I have no very clearly thought
out ideas with regard to the very broad subject
presented so well by Dr. Ross. I take it that he
looks to the future with some apprehension unless
the medical profession realizes its responsibilities
in a big way. I have this satisfaction in looking
toward the future: the medical men who are being
trained today in our medical schools are certainly,
as a group, the superior of any group that has
preceded them. Not that the best of today are
any better than the best of a generation ago, but
there are many more of them and in those young
men as they come into positions of influence in the
medical profession, I believe, is the hope of the fu-
ture of medicine. It is perhaps worth while to re-
member that the medical standards of these United
States of America are today higher than those of
any other country in the world, and that the edu-
cational standards of medicine are uniformly higher
than those for any other profession in this coun-
try. To illustrate what I mean let me say that
some law schools, some technical and professional
schools, enforce high standards, but all medical
schools have today universally high standards
which are enforced.
The other reflection that results from Dr. Ross'
paper and from other thoughts that I have had
with regard to this subject is this: I sometimes
wonder if the medical profession has not been
hypercritical of itself, whether we do not expect
too much of the group of medical men and whe-
ther after all medical men do not perform as well
or better than other groups and other organiza-
tions. I rather think they do, and I rather think
that it is a mistake to be hypercritical of ourselves
and our own work lest we create in the minds of
the public the idea that medicine is not living up
to its obligations as well as it should, or the dis-
proportion between what it should do and what it
is doing is far more than it should be. I believe
that the medical profession is partly responsible
for some of the misapprehension existing in the
minds of the public today. If such discussions as
this could be restricted entirely to medical groups,
well and good, but inevitably into the public press
and into other organizations have come up discus-
sions with regard to the obligations of the profes-
sion. I am rather one of those who think the pro-
fession performs reasonably well — to put it in the
vernacular, that our batting average is not below
the batting average of other groups. Once in a
while I think it would perhaps be better to praise
than to criticize.
These ideas are not well thought out, I am not
well prepared to discuss Dr. Ross’ paper and I
only make these remarks in order to promote dis-
cussion.
Dr. Vaiuler Veer: I think the examples that we
are all trying to set in our 3 medical societies as
represented here argue well for the obligations
which we have seen, and I think are foreseeing,
in our effort to meet with the public and the lay
organizations on common ground of discussion
where each has taken his or her part to bring for-
ward a satisfactory solution of public health
measures. We cannot do it all in 5 minutes and
neither can they, and I think it should be the aim
of the medical profession in the next few years
to keep alive this desire for mutuality.
Dr. Morgan: I have voiced this sentiment many
times in years past and am still strongly in accord
with the opinion expressed by Dean Patterson,
that the medical college is responsible for the mak-
ing of the physican-to-be, not only in respect to
his instruction in the various subjects that apper-
tain to medicine, but also in the larger field of
making him a citizen of the state and of the
nation, whose mind shall be so started both by
precept and example, started during his college
years, amplified during his intern years and fully
developed by the time that he becomes an active
worker in his own profession in the community in
which he may settle. Therefore, subjects indirectly
related to medicine, such as medical economics,
medical jurisprudence, preventive medicine in its
altruistic sense independent of the application of
medicine to the subject — all of these I think are of
vital importance to be stressed upon the teaching
profession so that when a man is sent out to
practice medicine he will also be a citizen of the
state with these 2 assets: he at once steps into
the foreground of economic value to his commun-
ity, and then after he has been trained it is up to
him in his sense of proportion as to how far he is
going to carry on in his endeavor to practice what
he has learned during his college years. Therefore,
this resolves itself always into the individual man
or woman. The more we can iterate and reiterate
Feb.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
161
to the student body the need of larger growth,
not only as physicians but as citizens, the more
1 think we will accomplish and the happier we will
oe for the effort put forth in directing the young
student's mind along the direction of his duty as
a citizen as well as a physician.
Dr. Sharpless: I only want to say this, that I
fully appreciate what Dr. Ross has said and I
think it is most important. I think that progress
i;i working with the public will depend a good deal
upon how willing we are to cooperate with the lay
health organizations that have been established
all over the country. They are good people, they
have an immense amount of public opinion back of
them and they have money. We should come into
these organizations, as they are the available means
of doing these things, and we should direct them
along the right lines. The attitude has often been
one of hostility, and some things can be corrected,
but I think they must be corrected by cooperation.
Dr. Donaldson: This subject, to my -mind, re-
solves itself into a division of the medical profes-
sion, that is, of those members who are in practice.
1 believe that men who have been in practice for
20 years or more will have an entirely different
attitude on this subject of responsibility to the
public from those men who have graduated in the
last 5 or 10 years, and who will graduate in the
future. Men who graduated 20 or more years ago
got through with their education in less time and
with considerably less money investment and they
knew nothing but service to the public as an
avenue of gaining clinical and practical experience,
so that their attitude, I believe, is a little more
generous than will be the attitude of the man who
has had to spend 7 years in study after graduation
from high school and whose parents have ex-
pended a considerably larger amount of money
than was formerly necessary on his education. I
do not believe that those young men will be as
willing to devote so much time or service to free
work, but will expect a quicker return for then-
money and for the time invested. It is my con-
ception that we older men should furnish the
leadership so that these younger men may not
be led into a position which will jeopardize the fu-
ture relation of the practice of -medicine and public
health, largely on a basis of quick return in cash
for services rendered.
I agree that we must relate ourselves as quickly
and as closely as possible to all organizations that
are interested in any way, shape or form in the
practice of preventive medicine; so, we at once are
confronted with skilled, trained minds, socialists,
psychologists, etc., who, unfortunately, have not
our angle of the practical side of even the prac-
tice of preventive medicine.
I might briefly relate what we are attempting to
do in my own county medical society. We have
an organization which we call our Welfare Fund
and have just completed a collection of $1,600,000
to help about 40 different organizations which
largely touch upon health. Our county medical
society, believing that it is the best equipped to
give advice from the health point of view, is ap-
proaching this welfare organization with a rather
unique proposition. We have made an estimate
that it would cost about $10,000 for our county
medical society to make the survey which we be-
lieve should be made in order that we might give
the best possible advice on relating health service
to these 40 different organizations. Inasmuch as a
great deal of the health work is now being done
by our members without charge, and inasmuch as
our 1300 members probably contribute consider-
able cash to this million and a half dollars, we are
going to work on the nicest terms possible in co-
operating with this welfare organization to the
extent of financing this survey which we hope will
result in better application of the medical and
health work to the problems that must be met. I do
not know how it will be received but, nevertheless,
that is the angle from which we are going to ap-
proach this problem. We want to make a survey as
to how the money that they are giving over now to
most of these organizations is being expended. They
claim that 20% of this money is being expended
each year in health work. We have reason to
believe, from our analysis of several organizations,
that the money is not being carefully expended,
but we want to approach it not from our angle
but we want to employ a sociologist to make this
analysis so that we may talk to them in their own
terms. We want to ask the sociologists to make
the survey but we want to be in control of it.
Dr. William H. Ross (Closing) : I think Dr. Pat-
terson made a very valuable contribution to the
problem in reference to the education of the young
men, but the young man of today has about the
same mental capacity that the young man of my
day had and he has to acquire about 3 times as
much in the same length of time and, therefore, it
is a process of selection.
I did not intend to give the impression that we
were criticizing the medical profession, but merely
wanted to stimulate them to see what is ahead.
All the discussion was very much to the point but
I want to emphasize that I did not intend it to be
critical of the medical profession, nor did I intend
to convey the impression that the medical profes-
sion should continue its long standing habit of
free work. If this could have been thought over a
little more I would have very definitely included
the remark that a part of the whole scheme is that
the doctor shall be paid for all the work that he
does in private practice or hospital service. Per-
haps it will carry with it the fact that he will lose
some of liis vested rights to become a millionaire.
I did not use any examples to show what the
public is thinking. New York State carried at a
recent election a $50,000,000 bond issue for its
service to the unfortunates, and it was carried by
a 6 to 1 vote. Steuben County, a small county of
New York State, where the medical profession up
to 2 years ago did not have a high conception of
its public medical service obligations, has since
that time established a public health committee
and various organizations in which the profession
simply guides them and this year a referendum,
even in these times of financial depression, was
carried so that $160,000 was voted for health com-
mittee service at public expense. In Tioga County
they have just opened the Tioga County General
Hospital and 3200 of 26,000 people living in that
county - contributed the money to build it. I had
the opportunity of talking to the medical pro-
fession and their visitors on the day of the open-
ing and 1600 people came to visit the hospital.
That is a very striking illustration of public in-
terest and an indication of the public viewpoint.
A very interesting point right there is that the
event advertised the fact that in that county they
have a Public Health Committee, the Tioga County
Medical Society, the Tioga County General Hospi-
tal, the State Charities Aid Association, and the
State Department of Health, all cooperating in a
program to advance preventive medicine and to in-
crease the conservation of life.
In the county adjoining mine, with a population
of SO, 000 people, the county medical society car-
JOl'RNAL Ob' THE MEDICAL SOCIETY Ob' NEW JERSEY
Feb., 1931
1 li:
ried a proposition at the recent election with an
appropriation of $2,000,000 for the establishment
of a County General Hospital. Now, these are the
straws that indicate that the medical profession is
awakening. Here and there you see striking ex-
amples of it and when the medical profession does
recognize the public viewpoint and does cooperate
we will have passed the stage of any criticism
of medicine. Practitioners of medicine should be
paid for their services, there should be no free
work, and there should be organization for in-
creasing the availability of medical resources, the
resources that we have told the public about and
have not done very much to make available. When
they are available, when the principle is established
that medicine shall be paid for its services, it will
solve many of its economic troubles.
The meeting adjourned for luncheon, where gen-
eral discussion was continued.
Dr. Reik: The next subject on the program.
"Should Licensing of Nurses be Brought Under
Control of State Boards of Medical Examiners?”,
was suggested by Dr. Patterson. I asked him to
present such a paper and he very modestly re-
plied that he was suggesting the subject because
he knew nothing about it. Dr. Van Etten was asked
to prepare a paper but he has been ill and could
not come. Dr. Kelley consented to give a talk but
was prevented from being present, so I think we
may ask Dr. Patterson if he would like now to
informally open up the question?
But, before proceeding in that direction, may
I answer a question that was asked regard-
ing our experience in New Jersey with group in-
surance policies. Several years ago an agreement
was entered into with the U. S. Fidelity & Guaranty
Co., in Baltimore, for a group policy protecting our
members against malpractice suits, which provided
also an indemnity fund in the event of judgment
against a member of the society. A very consider-
able percentage of our members has taken out
that policy. It is offered at an unusually low price
with the view, of course, of getting a large per-
centage of the members. In Warren County, for
instance, every member of the society has taken
out a policy. In the other counties there has been
a variable percentage, from 20 to 75. We have
2680 members and about one-half of them carry
that indemnity insurance. Three years ago we
made an effort to get health and accident insur-
ance, and full life insurance by group policies. We
had made a tentative arrangement but found that
the life insurance feature could not be carried
through because there are certain restrictions in
the laws of our respective states that make it very
difficult, hut it is possible to carry a group accident
and health policy. That was taken out with a
Philadelphia Company, has been in effect for 2
years and has proved very satisfactory. They issue
the policy to members of the State Medical Society
regardless of age. The price is low, slightly higher
perhaps than would apply to an individual policy
for the youngest of our members but not higher
than would apply to the average age of members;
for older members, it is very much cheaper than
anything they could get, if some members could get
any at all. Age makes no difference in the group,
and the company cannot cancel an individual
policy; it can only be done by canceling the entire
agreement with the society.
Dr. Morrison was last winter put into a rather
awkward position, in having to explain why our
state society dues had been increased to $15. There
was not the amount of objection that had been
anticipated but some few wanted to know what
was being done with the money, so we have just
completed the preparation of a pamphlet, which
is about the size of the little blue book put out
for the Woman’s Auxiliary last year, and the title
is: "Membership in the Medical Society of New
Jersey. Is it Worth What It Costs?” Dr. Mor-
rison has set forth in this book all the direct bene-
fits, such as the journal; then the indirect
benefits that come through association with public
health work, such as the antidiphtheria campaign
where we calculate that in the last 2 years a mil-
lion or more dollars were put into the pockets of
the physicians of this state; then the privileged
benefits, such as taking out the various types of
insurance. Incidentally, we have an automobile
group insurance policy which gives a rate about
the same as the general outside rate, with a 15%
reduction and also a 15% dividend at the end of the
year, which makes quite a marked total reduction.
We are also appending to Dr. Morrison’s report,
as to whether it is worth while to belong to the
state society, these specific types of group insur-
ance, the cost for a policy of each size, and con-
ditions under which the benefits are dispensed. We
will send a copy of that book to every member of
the state society, then to the county societies in
bulk to help in the collection of dues from the
backward members, and to be used in bringing
new members in a membership campaign.
Dr. Sommer : Does that health insurance policy
allow 6 weeks extra if the man is convalescing?
Dr. Reik: That policy now has a clause in it
which is not in any other policies available that I
know of. It provides for $50 a week for 26 weeks
in case of accident if you are house-confined and
it also covers a convalescent period when you are
not confined to the house. It is the most liberal
policy that I have seen and that clause has been
granted to us after 3 years of experience by the
company with our state society.
Licensing ok Nurses
Dr. Patterson: Of course, this subject has all
the elements of a row and it may result in that.
I always feel a certain sort of diffidence in dealing
with any problem concerning women because I
never had any influence with them individually or
collectively. However, I have a certain sympathy
for them and their difficulties and from the little
I know about this question of licensure of nurses
and of Nurses’ Boards it seems to me to lie be-
tween 2 extremes. On the one hand we have cer-
tain hospitals of restricted types of practice, in
which maintaining a nurses’ training school so-
called, is what I would call a particularly mean
and cheap way of getting a lot of work done; hos-
pitals in which there should be graduate nurses
paid for the services which they render, and when
hospitals of that type pretend to maintain a train-
ing school for nurses it is both a cheat upon the
young woman herself who enters that school and
it is a cheat upon the public. There is not the
slightest doubt about it. On the other hand is the
desire of the organized nurses’ societies to elevate
nursing to a high standard and to establish it as a
profession with self-regulation. In Duke Univers-
ity, for instance, which I recently visited in North
Carolina, the nurses’ training school of the hospi-
tal is put on the basis of a college course. Nurses
admitted to the training school have enforced
against them the same requirements for admis-
sion as against other students admitted to other
college courses and they have exactly the status
of college women, as well as the privileges of
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
163
dormitories and libraries, but instead of studying
for a science or artist’s degree, they are studying
for a nursing degree. Now, perhaps that is the
idea to which the nursing profession is tending.
In the Commonwealth of Pennsylvania we have
30,000 nurses who are all licensed; a very im-
portant group, of course. We have a nurses’ regis-
tration board which at one time was subsidiary to
the Medical Licensing Board but some years ago
was detached and is now independent of any
medical control. The complaint is made that this
Board has become extremely arbitrary, that it has
gone to various hospitals and has served notice
upon them that this or that thing is not to their
liking, that they do not approve of the dormitories
or reading rooms or bath rooms or some other
provision made for the nurses, and they do not
approve of more than 1 nurse sleeping in a room,
etc. They have even asked to see the plans of
hospitals before they were built and in some in-
stances have served notice that those plans were
not satisfactory and if built according to those
plans the hospital would be stricken from theii-
list, which would mean that the hospital would not
be able to maintain a training school. Now this
Board is pursuing exactly the same arbitrary
methods that were pursued by medical examining
Boards 20 or 25 years ago, when they served notice
on medical schools that unless they did so and
so they would be taken from the approved list.
The nursing boards are not doing anything that
our own boards have not done.
I suggested this topic for discussion because I
have been unable to know just how this matter
ought to be controlled. I am certainly sympathetic
with the desire of the nursing profession to main-
tain satisfactory standards, and I do believe that
there are certain so-called training schools that
do not deserve the name and that should be closed
up, and the work which is done by so-called pupil
nurses should be done by paid graduate nurses. I
think when a training school is maintained because
it is 90% of advantage to the hospital and 10%
to the young woman there is something wrong
about it. On the other hand, it does seem to me
that there should be some regulation, some con-
trol of Nurses’ Registration Boards. They should
be in some way related to the medical profession.
If the nurse is the doctor’s helper, she should be
willing to occasionally take counsel and advice
from those whom she professes to help and from
whom she receives her instructions. Now, how
should these nurses’ examining boards and regis-
tration boards be organized? Should they be in-
dependent of control or under medical regulation?
How sympathetic should the medical profession be
to the aspirations of the nurse to as rapidly as
possible effect an elevation of standards, to per-
haps go through something of the same evolution
that medical education has gone through in the
past 25 years? I am sorry that there are not some
nurses here, for perhaps I could arouse them to
such fury that they would discuss the question
fully. I should like to know from the doctors
around this table, who know more about this sub-
ject than I do, what their opinions are.
Dr. Ross: Dr. Patterson has exactly pictured
the situation in New York as I know it. It
sounded to me as if he might be a resident of
New York, as he was talking of this situation. I
am in such complete sympathy with what he has
said that I really have nothing to add. He has
pictured a very true condition. I can add just
one little supporting illustration. In 1 hospital
that I know of the Examining Board of Nurses
said that it would not approve of the gradua-
tion of its nurses because some undergraduates
were employed. When asked if they had not the
right to do that, they said “yes”, but the facilities
for caring for the nurses were not perfect, as the
graduate and undergraduates had to use the same
lavatory. That was the sole objection to the edu-
cational facilities in that institution.
Dr. Sharpless: I believe that Dr. Patterson has
had some experience in a small hospital. I have
been connected with a hospital of 125 beds in a
town of 14,000 people and we are constantly being
corrected and advised by the Bureau of Nursing
Education and about certain matters that we think
are unnecessary. For instance, they require that
certain examinations of patients be made that are
of no advantage to the patient whatever, but
simply in order that the nurses may have exper-
ience in that particular kind of work. They have
also told us that we must have an assistant to our
Superintendent. Wp think she does not need an
assistant, she has 8 or 10 supervisors, each in
charge of a department, but they say that is 1
of their regulations — that the Superintendent must
have an assistant — and they will impose upon us
the expense of $1200 or $1500 a year which we
can very poorly afford in order to carry out their
theory and to supply a person whom we think we
do not need. Otherwise, they will take us off the
approved list. Now, it may. be that our hospital
is one of those that should not have a training
school, but our nurses all take the State Board
examination and pass it and we think that our
nurses are well trained.
Furthermore, I think that we do not now edu-
cate and give to the public as good nurses as we
did 15 years ago when educational standards were
not so high. I think they have made nursing
mechanical and do not now teach them the de-
velopment of personality, the value that there is
in the personal touch and the personal under-
standing and sympathy for patients, which the
nurses had some years ago. I may be mistaken
about that but I judge largely from my own ob-
servation and 1 believe that the nurses that are
now trained in Pennsylvania are not as well train-
ed as formerly in care of the sick. They get
a better education, learn a lot about bacteriology
and psychiatry which are made little use of, but
they do not learn as much about how to take
care of the sick person as nurses did years ago.
Dr. Morgan: I may speak specifically about
Pennsylvania, probably reflecting a similar condi-
tion existing in other states. I think the nursing
situation has gotten out of bounds in respect to
having nurses in hospitals to be assistants to the
physicians, to act under orders and directions with
the primary object on the part of both the bene-
fit to be derived by cooperation between physicians
and nurses in the welfare and care of the patient.
From observation I am fully of the opinion and
I have heard expressed on many occasions in the
past couple of years, that the present day product
of a nursing school shows that the young woman-
sent out supposed to be a fully trained nurse, has
knowledge of a test tube in inverse proportion to
her knowledge of the use of the bed-pan.
Dr. Yander Veer : In New York State, as you
know, all the educational schools are under the
Board of Regents. Subservient to the Regents is
the examination and licensing of nurses. Now
we are going through the throes of a period where
we have pressure brought to bear by the nursing
group to elevate their profession. They lay down
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
1 04
ihe law to certain hospitals. They have, however,
elevated the profession to a very marked degree
until they are now becoming rather overbearing.
At the same time they have brought this to pass
with a number of small hospitals which do not
come up to the standard : Many of these hospitals
that are lacking in obstetrics, for instance, have
their nurses take courses in obstetrics at other
institutions. We have in Albany 1 hospital that
does not have the required amount of obstetrics
and pediatrics and those nurses go to New York
to take such courses before getting their certi-
ficates. We have a number of smaller hospitals in
New Y ork State that have to meet the same prob-
lems. Some of them send their nurses to Syracuse
and to other cities for this complete curricular
work. However, we are getting to where some
of the nurses tell us what to do, and we do not
like that. On the other hand, we are getting some
nurses that do not know enough to do nursing
and we really do not know just what is the proper
move to make. A nurse who is graduated in New
York State cannot practice nursing, except under
the domestic or certified nurse rule, which is a
rather questionable ruling, unless she has passed
the State Board and received the degree of R. N.
from the Board, and not from the school from
which she has graduated. Those interested can
write to the Secretary of the Board of Regents
and get the gist of the law, and also to the State
Board of Examiners for Nurses. I think you will
find they have solved part of the problems but
not all.
Dr. Lawrence: I have been working with Dr.
Y an Etten and Dr. Harris for several years in-
vestigating the nursing situation in New Y'ork
State. Things have quieted down somewhat but I
do not know what effect our work has had. We
have gotten as far as Dr. Patterson hints his state
might go. Our nurses’ training schools have dormi-
tories with names such as Winchester Hall; they
are real college institutions and we recently raised
the requirements to a full high school course. The
medical society approved of that and immediately
the Board of Regents raised the requirement to a
4 year high school course. YVe have a number of
nurses in the Nurses’ Association who are eager
to see the training equal to that of any other
college course and they are also very desirious
of having all nursing done in the institutions
or private home limited to these registered
nurses. That has been pointed out a number
of times to work a great hardship on the sick but
that argument does not seem to carry the same
weight to the general person interested as it does
to some of our physicians. Now our hospitals have
had exactly the same experience with regard to
the type of building the nurses shall occupy and
the. facilities that shall be given to them for train-
ing. One nurse at a meeting of the Nurses’ Asso-
ciation stated that she felt the hospital was the
laboratory of the nurses training school and should
so be considered.
I am not so sure that adding physicians to the
Examining Board will give you a remedy for the
conditions because we have physicians on our Ex-
aminging Board and they have written the most
elaborate curricular in a book 6x8 inches of or-
dinary sized print. The physician who outlined
the course in surgery occupied 11 pages which
must be taught to these nurses. It is the most
outlandish affair that was ever prepared and handed
out, the idea that a nurse should undertake the
work outlined in that book, with the number of
hours required, and the type of questions asked.
I would be glad to send some sets of questions
that have been asked by the Regents. If you or I
could pass those examinations we would be very-
well content that we still knew some of our medi-
cine and when those girls pass that examination
they are entitled to feel that they have a right
to dispute with the doctors, and do not hesitate
to do it.
1 believe one approach to this matter is through
the hospitals themselves. There are hospital su-
perintendents who are exceedingly ambitious to
have large training schools. Some of those are
among the most influential men in the state. They
are proud of the training schools and are determin-
ed to have them all raise the qualifications, and the
public is paying the bill through the charges made
for hospital patients. I do not believe that you will
get a complete remedy by putting physicians on
the Board but I think the main approach is through
the hospitals. Some of them insist on training the
nurses in their own way and are getting away with
it.
Dr. Hammond: My feeling is that if it could be
accomplished it would be to the best interests of
the profession. If the nursing profession takes
the attitude, and it is given widespread publicity,
that the profession knows little or nothing about
the nurses’ training school, it will be thought that
the physicians should not have full control. I have
heard of 1 hospital where the personnel consisted
of 3 persons, 2 graduate nurses and 1 physician.
The physician told me that it was a farce to have
meetings because he was always voted down.
In Pennsylvania our Examining Board consists
of 3 nurses. There is no longer a physician on the
Board. The nurses have given publicity to the idea
that physicians should keep hands off so far as ad-
ministration is concerned. On the other hand. I
think it is to the best interests of medicine if the
Board of Registration of Nurses could be eliminated
and the matter brought under the control of the
State Board of Medical Examiners. I recall that in
Chicago a couple of years ago, discussing this ques-
tion with a Professor of Neurology, he said that
as a matter of trying out the questions given in
the State Board of Registration of Nurses he gave
those questions on neurology to the third year
medical students in their final examinations and
some of them fell down badly. That is true among
many other departments of the academic work of
the Nurses' Training Schools. I think it would be
a big thing if this question could be controlled by
the Board of Medical Examiners, but there would
be tremendous opposition to such a proposition on
the part of nurses.
Dr. Hammer: YY’e, of course, have a State Board
of Nurses and I can see from this discussion that
we have lost sight of one very important indi-
vidual in this nursing problem, and that is the pa-
tient. If the patient did not exist the hospital
would not exist, and there would be no call for
either nurse or doctor, and it seems that in the
regulations that these Boards send out every year
for guidance of the profession and the care of
nurses they have lost sight of the real interests
of the patient. Last year the Board of Nurses
passed our hospital all right but suggested that
we have a Board of Managers for our training
school, consisting of a lawyer, the head of the
training school and a lay person, intimating that
the physicians, a committee of 3 from the staff
who had charge of the training school, did not
know how to run a training school. A rather
startling sort of message to send to the head of a
Feb., 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
165
hospital, that the physicians themselves were not
fit to be managers of a training school. That
savored of what you might call trade unionism.
Furthermore, the individual that we looked upon
as a handmaiden and a worthwile adjunct to the
care of the sick is now trying to be our master
and to teach us how to practice medicine.
Lately there has been another endeavor, that is
to institute in our hospitals a department for men-
tal diseases. We all know that these girls who are
being trained to be nurses are not at an age
where they would be competent to take care of
mental cases, nor is it right to house mental cases
with other patients, even though you have a
separate building, and to put them under the
care of the ordinary undergraduate nurse. I have
had many years’ experience with the State Hospi-
tal in Trenton in various capacities and I know
the type of nurse there is much older than those
who apply for our training. I cannot see where an
exchange of nurses between a mental institution
and a general institution would have any advan-
tage. Rather should it be that the nurses who
want that sort of training should get it as a
post-graduate training than as undergraduates.
Then comes the question of an individual room
for every nurse. Certainly these things are very
idealistic and very nice. I take it that the average
girl would prefer to have a companion, however.
The outcome of all this is that it raises the cost
of medical care and therein lies a factor that the
nurses’ training boards do not take into considera-
tion. In municipal institutions it raises the tax
rate. We say that we should not care about that,
nevertheless everybody does care whether the tax
rate is higher. Certainly the tax on the individual
patient is higher each year. The patient is very
frankly told that she must have 2 special nurses.
That was not true In days gone by; patients were
contented with 1 nurse even though she did not
give all of her time to that patient. Therein lies
another of the objections to the regulations of our
various nursing boards, as" I see it from the stand-
point of one connected with a general hospital for
30 years.
I am in accord with the idea that this is really
a hospital problem but medical men should at least
have some sort of a representation and preferably
an equal one upon these boards. I think the nurses,
left to themselves, have gotten far away from
Florence Nightingale’s original idea of nursing
service to the patient.
Dr. Reik : If it meets with your approval I will
ask the New Yrork representative to put this topic
on the program for the midwinter meeting with a
formal paper, particularly if we can get Dr. Van
Etten to give it, and a fixed discussion. The sub-
ject has been before the conference before, some 3
years ago, at the time when Dr. Van Etten had just
been appointed- by the A. M. A. to study this ques-
tion.
While we are discussing the examination of
nurses, I am reminded that the Medical Society of
New Jersey is somewhat perturbed at this very
moment by the fact that a special session of the
legislature is considering passage of a law that
would combine all of the state examining and
licensing Boards into a new bureau to be estab-
lished in the Department of Public Education.
This comes about as a by-product in an attempt to
reform methods of handling- public funds. There
has been much complaint about extravagance and
waste of state money,, and after investigation by
a special commission, recommendations have been
made for revision of the present methods of budget
preparation and legislative appropriation. Funda-
mental measures, among a series of bills designed
to put the commission’s recommendations into
force, provide that all money received by licensing
Boards, as well as by all officers, committees, and
other Boards transacting state business, shall be
paid into the general treasury, and that each Board
shall annually request an appropriation for con-
duct of its business. The State Board of Medical
Examiners has been accustomed to retain all funds
received from examination and licensing fees, and
from fines collected from illegal practitioners, and
to use the excess over office expenditures for en-
forcement of the Medical Practice Act. As good
citizens, members of the medical profession ap-
prove the principle involved in the provisions for
treasury control of all moneys and expenditure
only by budgeting and proper appropriation, but
our members and the Board of Examiners fear
that if these funds are surrendered to the general
treasury it will be difficult to secure appropria-
tions sufficiently large to carry on the Board’s
work as well as it has been done. So, at the pres-
ent moment, we are much concerned over the pos-
sibility of the legislature enacting this law.
Dr. Sharpless : I do not think it is any hardship
to ask these nurses to come in and work for 3
years at a small salary. They leave at the end
of 3 years to enter the best paid profession open
to women. I think they are fortunate in being
given an opportunity to get such training. I have
visited many of the training schools and Dr. Pat-
terson has done the same thing but we seem to
have come to rather different conclusions about
having training schools in many of the hospitals.
Dr. Patterson and his co-workers are about to
introduce a new medical practice act in Pennsyl-
vania and I would like to see that act put the con-
trol of nursing under those who are charged with
its enforcement. It is not a proper thing for the
nurses to do this unaided and unadvised and it
would be a good thing to put the whole affair under
one head, a commission that will include all sorts
of regulations enacted for the practice of medicine.
Dr. Patterso?i: Dr. Sharpless and I do not disa-
gree at all. We are generally in agreement. I
agree with what he has said and I am sure that
he will agree with me in what I am about to say.
I think, in the first place, that any hospital that
establishes or maintains a training school for
nurses assumes a certain obligation to provide that
pupil nurse with certain things. First, she should
get an adequate experience in the various branches
of medicine; secondly, the school owes an obliga-
tion to her to see that she has adequate facilities
for receiving certain instruction,- other than purely
bedside nursing, and of course she should be
properly housed and fed. The staff should be
adequate to carry on a course of instruction.
I do not think that all hospitals should have the
same standards but Dr. Sharpless will agree .with
me, I am sure, that there must be some minimum
educational standard to be applied to those ad-
mitted to such training. And I do not think that the
hospital should be altogether selfish about it. It is
one of those undertakings which carries with it
an obligation to do certain things that may not
be profitable. Medical education is the most un-
profitable thing to be engaged in. The tuition fee
probably pays about one-half the cost of instruc-
tion. I think the same thing should apply to
nurses, that the hospital should regard its train-
ing of nurses as one of its contributions to public
welfare.
Unless you do have some sort of minimum stand-
166
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
ard established by some authority the result is
that hospitals will bid one against another for
young women to go into their training schools.
That was true once of medicine. The lowest grade .
schools would admit students with the least pos-
sible requirements for studying medicine. I do not
mean to refer to the smaller hospitals, such as the
admirable one which Dr. Sharpless heads, but he
knows and I know that there are some hospitals
that really do not provide adequate experience,
adequate laboratories or diet kitchens and demon-
stration rooms adequate to give nurses even ele-
mentary instruction in some of the things they
should know, and those training schools should be
dropped. I do not believe there are very many
such hospitals, however. I do agree also with Dr.
Sharpless that some of the requirements are un-
reasonable. I know our medical students live in
their domitories and fraternity houses, sometimes 4
in a room with doubledeck beds. Under the regu-
lations of the nursing board the nurse is far better
provided for than is the average student of medi-
cine. Sometimes 2 bathrooms will suffice for 25 or
30 men and they get along somehow and turn out
to be reasonably good doctors. I think that some-
where between the extremes of what those will
have in mind who want to elevate the standards of
the nursing profession, and way down at the bot-
tom with the hospital that does not offer adequate
training, there is some middle ground where the
standard should be fixed and maintained and en-
forced, I have a notion that nurses' examining
boards’, medical and dental examining boards should
be under some control outside of themselves. I
believe that would be a good thing for all of us.
Dr. Reik may be interested to know that in
Pennsylvania we have exactly the system that he
now fears having imposed by the Legislature. W e
have a budget system and a secretary of the budget
to whom the applications from various departments
must be made for all appropriations. All fees re-
ceived are paid into the public treasury and all
budgets are handled by the secretary. It has not
worked out badly and could perhaps work out very
well. The problem then becomes one of getting an
item into the budget adequate to the purpose for
which it is intended. Our medical board works
under exactly that system.
Dr. Reik: Do you get money from them for
prosecution of illegal practitioners ?
Dr. Patterson: Yes. There is an assistant at-
torney general to do the prosecuting. The Board
has 2 investigators who go around and collect evi-
dence. The state will also cooperate in that en-
deavor. However, our budget item is not fully
satisfactory and we want to change that under the
new law. In Pennsylvania we have no Board of
Regents but our proposal is to set up an adminis-
trative board of governors for the healing arts.
In a sense it will be a Board of Regents restricted
to the medical arts and under that administrative
board the examining boards will be appointed to
conduct special examinations and to report the
results of those examinations and the Board of
Governors will issue the license instead of the
Examining Board. That will make a better group
of examiners who will not be responsible for de-
ciding questions of standards. On that administra-
tive board there will be educators and some repre-
sentative of the public, and certain ex-officio mem-
bers of various departments. I have a feeling that
our position in medicine would be stronger if we
could give over a certain part of our authority
at present vested in the examining boards. If we j
do that it means allaying the criticism by many j
that the doctors control the thing in their own |
interests, and I have no fear of the results.
My experience in Pennsylvania, on the Commis-
sion of the Healing Arts, was rather revealing,
There was a board of 12 and on that board was a J
Bishop and a Judge, and they were the 2 best sup- ,
porters I had for the establishment and main-
tenance of satisfactory standards of technical edu- ■
cation. You do not need to fear men like that I
and they are a good sort to get behind and let
them make our fight for us. If they will take the
lead it will relieve us of a criticism that we are
controlling things for our own interests.
You might be interested in hearing a little more '
about the budget system in Pennsylvania, but if
it works as well with you as it has with us you
need not fear it for you have enough influence to ■■
get written into the budget items for sufficient ap- jj
propriation to carry on certain work without re-
gard to whether the fees are more or less. When
the appropriation is less than the fees we make
an awful howl but at other times do not say any- i
thing.
Dr. Reik You have a special registration tax, I
believe?
Dr. Patterson: Yes, $1 a year. That bears no
relation to the sum set aside. It is a very valuable
aid to law enforcement. The fee paid should be
just adequate to the cost of conducting registra-
tion, maintaining a register, publishing it and
supplying to each registrant a copy of the list
registered. That immediately calls attention
to any illegal practitioner. In Kansas they re-
cently put a man off the State Board who had
never been licensed to practice medicine but who
had been serving on the State Board of Examin-
ers for several years. Annual registration and
publication of the list will reveal many men in
certain communities who are not registered at all.
It is a good thing to conduct it annually, and $1
a year will cover the cost and this is a very small
fee. In North Carolina they charge what they
call an occupational tax and every doctor pays
$25 a year, so we should not complain about a
nominal fee that just about covers the registra-
tion itself.
Dr. 8harj)less: I agree with everything that Dr.
Patterson has said and I am very glad that he is
President while our Bill is going to the legislature.
I think it is the duty of everyone to support him
heartily. Every difference of detail should be
thrashed out before the bill is presented and then
we should all get behind it.
Dr. Patterson: 1 am much indebted to those who
took part in the discussion and am sure it was
very helpful.
Dr. Donaldson : I wonder if it would be well at
the next meeting to go so far as to have some
one present the nurses’ side of the question?
Dr. Reik: We have at times invited outsiders to
take part in the discussion.
Dr. Do7ialdson : I think it would be interesting
to have some proponent of the nurses’ point of
view speak to us.
Dr. Sommer: I think it might be well to have
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
167
some one from the Board of Nurses’ Examiners
of each state. I believe also that we should have
a representative from the New York Board of
Regents.
Dr. Reik : Regarding the pending legislation in
New Jersey, what we fear is not that there is any-
thing wrong with this theory but we fear its pos-
sible political working. If we could name the
Commissioner of Education we would be satisfied,
but that office has at times been a football of
politics. The present incumbent, Dr. Elliott, we
would be quite willing to trust to direct the whole
affair, but we do not know who his successors
will be. I think we could always bring enough
influence to bear to get what money we needed to
be appropriated, and possibly get more money
by that means for prosecution than we have ever
been able to get by any separate and distinct bill.
There has been opposition in New Jersey to an an-
nual registration bill. Our Welfare Committee
drafted such a bill, voted by a majority of 5 to 1
to advocate its passage, but 1 county society ob-
jected so strongly that we withdrew the bill be-
cause we did not want to go before the legislature
with divided forces. They objected to the same
thing that you have discussed in Pennsylvania —
the medical profession would be taxed for a fund
to enforce the laws. But unless we provided the
money in some way we knew the law would not
be enforced. We have had a special deputy from
the Attorney General’s office to conduct all of the
trials, who has been very sympathetic and ener-
getic, and our Board has combed the state pretty
thoroughly during the past 4 years searching out
illegal practitioners; but if we surrender control
of that fund to the general treasury it is felt that
we will find it hard to get it back again for en-
forcement purposes. It may be an unreasonable
fear.
Dr. Patterson: It is well said that the doctors
should not be called upon to enforce any law pro-
vision by a pecuniary contribution, but if you re-
strict the fee paid merely to covering cost of reg-
istration itself it would be a very valuable thing.
Dr. Ross: New York has a $2 tax and the Board
of Regents is very well pleased with the results.
They have utilized that fund for pretty much all
transactions.
Dr. Donaldson: I would like to voice the senti-
ment of the Pennsylvanians present in our appre-
ciation not only for having provided us with a
good program and a good luncheon, but also for
having these ladies to grace the table today.
Dr. Sommer: We are indeed glad to have the
men from Pennsylvania and New York here today
and as we have become better acquainted it makes
the gathering much more happy.
Dr. Lawrence: I would like to invite the Tristate
Conference to New York for its next midwinter
meeting. It is customary to come over there for
the winter meeting but we do not want you to feel
that you are not invited to come.
Motion was made by Dr. Reik that the invitation
be accepted, which was duly seconded and carried.
Adjournment at 3 p. m.
In Lighter Vein
Breakfast Nook Repartee
“Anybody would think I was nothing but the
charwoman!’’
“Especially if they saw this toast!” — Life.
Service Plus
Billfuss — “I wonder if that fat old girl over
there is really trying to flirt with me?”
Goodman — “I can easily find out by asking
her; she is my wife.” — Pathfinder.
Broadminded
“Did I leave an umbrella here, yesterday?”
“What kind of an umbrella?”
“Oh, any kind. I’m not fussy.” — Boston Trans-
script.
It’s a Topsy-Turvy World
“Times certainly have changed,” sighed Smith.
“How so?"' asked Robinson.
“Why, at a little family party last night, the
women talked politics while the men got off in
a corner and exchanged recipes.” — New York
Times.
Hymn of Hate
Two Negroes who had been engaged to mow
the lawn of a big hotel were quarreling.
“Niggah,” said one, “does yew know whut I
done wish? I done wish dat hotel yonder had a
thousan’ rooms in it, and that yew wuz laid out
daid in e’vy room!” — Tit-Bits.
Making of a Home Body
Mr. Y'earwed- — “A bunch of pretty college girls
have opened a mending shop near my office. I
think I’ll turn all my socks over to them.”
His Wife — “Poor boy. I have neglected your
socks. But leave them with me. I like to darn.
I really do.” — Boston Globe.
Wuss, Wusser, Wussest
Sambo, a Southern darkey, married Liza. In
about two weeks he came to the reverend gentle-
man who had tied the knot, looking as if he had
lost his last friend in the world.
“What’s the matter, Sambo, aren’t you happy?”
the preacher inquired.
“No, suh, pahson. Ah wants a divorce.”
“I'm sorry to hear that, Sambo, but you must
remember that you took Liza for better or worse.”
“Ah knows dat, pahson, but she’s wuss dan ah
took her fo’.” — News Bureau, quoted by the
Christian Leader.
Diplomacy
“Did you make the debating team?”
“N-n-no. They s-s-said I w-w-wasn’t t-t-tall
enough.” — Jack o’ Lantern.
Domestic Yes-Man
“The man who gives in when he knows he is
right is weak,” says a novelist.
Or, of course, married! — Border Cities Star.
108
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
Public Relations
STATE MEDICINE AND CONTROL OF
SPECIALISM
(Abstracted from the Presidential Address of
Dr. John A. Hartwell, delivered at the Academy
of Medicine, New Yrork, January 7, 1931. These
particular sections of President Hartwell’s ad-
dress, dealing with problems and conditions so
similar to those facing us in New Jersey, are
worthy of careful consideration. Furthermore,
the recommendations and means for making ac-
tion effective seem just as applicable to the Medi-
cal Society of New Jersey as to the Academy of
Medicine of New York, if we cannot devise bet-
ter plans. Other portions of the address dis-
cuss other subjects of importance and great in-
terest to the profession, but we choose these
topics for a distinct focusing of attention. — Ed.)
Every undertaking must have a leader. The
Academy can and should be the leader in the
betterment of medical practice in every way that
offers itself. Much fear is at present expressed
that doctors are losing control of their own des-
tiny; that lay bodies and the state are tending
to become our dictators and that our freedom of
action is being taken from us. If there bo any
ground for such fear, this Academy is so situated
that it can accept the challenge and demonstrate
the ability of the medical profession to shape
its own course on a road of sound endeavor.
The practice of medicine has not escaped the
disturbing influences which are appearing at this
time, in all human activities. A reading of books,
magazines and the daily press only too surely
demonstrates that almost everything of the ac-
cepted order is under attack. There is abroad
a spirit of skepticism and unrest. Knowledge of
biologic processes has advanced and is advancing
more rapidly than it can be assimilated and ap-
plied to the complex matter of maintaining good
health and restoring it when lost. The laity is
impatient at this.
Every physician is driven into limiting his ac-
tivities to a comparatively small field. Even then
he constantly finds himself faced with problems
of public and individual ill health which tax his
resources and to which he finds great difficulty in
applying accepted facts which the scientific in-
vestigators have established. To meet this sit-
uation he constantly is confronted with the neces-
sity of calling to his aid other doctors. Thus
the specialist was called into existence and, once
created, the growth of specialism has been rapid
and largely uncontrolled. It is now necessary
to review this situatior and place the practice of
the various specialties in the hands of men who
are competently and completely trained.
Critics of the medical profession call atten-
tion to the fact that there exist in organized
medicine no means by which the patient is able
to be well guided in the selection of his physi-
cian. Reasons for this are partly the responsi-
bility of the doctors and partly of the patients.
It is true that as at present organized, the state
licenses a practitioner of medicine and thereafter
exerts no control over him whatever, unless he be
guilty of a felony. He is at complete liberty to
undertake the care of any type of patient and
to institute any therapeutic measure that he
deems advisable. If the public, therefore, is to
be served in the best way. it is necessary that it
should have information that will permit the se-
lection of a physician who is fully fitted to meet
its requirements. The furnishing of this in-
formation would seem to be a function of the
profession itself.
Many publications, both by members of the
medical profession and the laity, appear at the
present time more or less strongly urging the
necessity of state and federal control of the prac-
tice of medicine. A careful study of much of this
fails to impress one with the belief that the ar-
gument is carefully thought out. There can be
no gainsaying the fact that, in the last analysis,
the health of the community and of the indi-
vidual is a matter of public concern in which
every individual, whether well or ill, has an ac-
tive and definite interest. It cannot be denied
that illness, as such, is a charge upon the entire
community, directly on indirectly; that enor-
mous sums of money are expended in an effort to
maintain good health; and that, under ideal con-
ditions, this amount could be greatly reduced.
The state already has a very active part in this
work; and we believe, many statements to the
contrary notwithstanding, that the medical pro-
fession as a whole, is solidly behind the state
and federal government in every effort to dim-
inish individual or public ill health.
The accusation is made that the individual
doctor is little concerned with this endeavor;
and the more cruel accusation is made that his
unconcern is stimulated into active opposition be-
cause of the fear of financial loss.
It is true that many doctors, because of the
lack of proper emphasis in the medical college
curriculum, have not developed a broad view of
the possibilities of preventive medicine and the
public health as entities. To say, however, that
they are not interested in these things and that
they place themselves in opposition to real prog-
ress because of an ulterior motive, is, I believe,
far from the truth. If organized medicine op-
pose itself, at the present time, to governmental
control of the practice of medicine, it does so
only because it is not convinced that either in-
dividual or public health would be thereby con-
served.
The British Medical Association states that it
has been giving serious consideration to this
problem for 30 years. It has evolved a plan,
for use in Great Britain, which was published as
a supplement to the British Medical Journal of
April 2G, 1930. The hub upon which this en-
tire plan centers is the increased importance of
the family doctor. Whether the patient be en-
tirely independent and financially able to bear the
full responsibility and cost of illness, or whether
he be at the other end of the social scale, the
relation between the doctor and patient shall
be personal and individual without the interven-
tion of any third party. The report states that:
the medical service of the community must be
based on the provision for every individual of a
general practitioner or family doctor.” * * *
Insofar however, as the individual doctor can
promote the prevention of disease, this can best
be secured by associating every general prac-
titioner with the general health service and em-
phasizing on every possible occasion the fact that
there is no real lino of demarcation between the
preventive and curative branches of professional
work: and, that a satisfactory system of medi-
cal service must be directed to the prevention of
disease no less than to the relief of individual
sufferers.
I believe that organized medicine in this coun-
try will be found entirely in accord with these
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
169
statements and that it will fully cooperate with
governmental agencies in putting them into ef-
fect. The problem, however, is too complex to
permit of a sudden transition from long estab-
lished custom to a revolutionary change that
would be in need of constant revision.
The Committee on Education has taken the
lead in studying the problem of specialism and
the education and qualification of specialists. A
subcommittee under the chairmanship of Dr.
Eggers has been engaged in the work for nearly
2 years and in association with the Committee
on Sections, the Committee on Admissions and
interested Fellows, a concrete plan was present-
ed to and adopted by the Council at its meeting
on December 17. The Council will later submit
proposed changes to the By-Laws which, if
adopted by the Fellowship, will make the plan
operative.
The proposals have 2 definite aims. First, to
stimulate the activities of members by a form
of promotion, and second, to lay down qualifica-
tions in the various specialties which will have
the approval of the Academy. Conformation to
these will qualify a Fellow in the given specialty,
and the Academy thereby becomes his sponsor as
competent in training and experience to practice
such specialty. Ultimately a, way may be found
whereby doctors, not Fellows ' of the Academy,
may be so certified and thus the public be in-
formed as to fully qualified specialists through-
out the city. The details of the proposal will .be
published in the Bulletin and only a summary
is given here.
It is proposed that 2 classes of membership be
created in the Academy to be known as “Mem-
bers” and “Fellows”. A doctor, being elected to
membership becomes a “Member”, qualifications
for Members to remain the same as the present
qualifications for “Fellows”. Upon election a
Member shall be assigned to the section of his
choice. Each section, through its Advisory Com-
mittee, shall set up, with the approval of the
Council, qualifications to which a member must
conform if he desire to be promoted to Fellow-
ship and designated as Fellow in that particular
specialty represented by the Section. For ex-
ample: Fellow of Internal Medicine, or Fellow
in Gynecology, etc. In general the qualifications
required shall be similar to those set up by var-
ious national associations and societies in the
special fields.
A Fellowship Committee, corresponding to the
Committee on Admissions, shall be elected from
representatives designated to the Nominating
Committee by each of the sections. When a
member of any section shall have submitted to
the Advisory Committee of his section sufficient
evidence that he has met the qualifications ap-
proved for Fellowship in that section, his name
shall be submitted to the Fellowship Committee
in the same manner as applicants for member-
ship are submitted to the Committee on Ad-
missions. If the Fellowship Committee approves
of the recommendation the member shall be
voted upon by the Academy as a candidate for
Fellowship of the New York Academy of Medi-
cine in that branch represented by the section
recommending him for Fellowship. Any pres-
ent Fellow of the Academy will have the priv-
ilege of being also designated if he so desire, in
the same manner. If approved by the Fellowship
Committee and by the Council, he shall become
a Fellow in the particular specialty, without fur-
ther action by the Academy as a whole.
By the adoption of the proposed changes the
Academy will take a definite step toward real
organization in the matter of specialism. And
if our program for continued education eventu-
ates there will be provided the facilities whereby
the candidate for specialism may properly re-
ceive adequate training under competent super-
vision.
HOW SCIENCE NIPPED AN EPIDEMIC
(Editorial, Newark Evening News, Jan. 17, 1931.)
Three reports of undulant fever reached the
State Board of Health from somewhere in New
Jersey. What undulant fever is, while doubtless
of considerable moment to the sufferer, need not
be debated or surmised. What is important is
that the illness was promptly traced to raw milk
and to the dairy producing it. The dairyman was
immediately ordered to pasteurize all his milk,
by authority of a law passed in 1915.
Not so many years ago the cause of the illness
might have remained unknown, the source of the
infection a mystery. It would have been the same
had»the malady been typhoid or something else.
Science has done marvelous things in the in-
terest of public health, as is of common knowl-
edge, with the assistance of state and municipal
regulations. It is just one manifestation of this
that an isolated case of illness frequently leads
to the discovery of a condition which might
easily become an epidemic, taking toll of many
lives.
In this instance, 3 cases of a certain illness at-
tract attention. Science knows its probable cause.
The source is found, and further danger is elimi-
nated though recourse to a law framed to meet
just such an emergency. Much sickness is pre-
vented. Probably many lives are saved.
-Sometimes the trail is not so plain. It may
lead from the home to the little milk distributer
and from him to the wholesaler. Inspection of
many samples of milk from many herds of cows
may be necessary. Thanks to efficient regulations,
that is possible. These regulations, state and
local boards of health, bacteriologists and in-
spectors who know every cow barn in the state
are constantly guarding the public health. It is
a comfortable thing to know.
School Health Department
STANDARDS FOR PREVENTION AND CON-
TROL OF CONTAGIOUS DISEASES
Allen G. Ireland, M.D.,
Director of Physical and Health Education, State
Department of Public Instruction, Trenton, N. J.
Opportunities at School
(1) Daily congregation of children at school
facilitates observation, detection and supervision.
(2) Administrative organization of the school,
together with the trained intelligence of its per-
sonnel, presupposes control of procedures and en-
forcement of regulations.
(3) Contact with the parents of pupils is al-
ways possible.
(4) Education, which is 'the chief function of
the school, is the most effective approach to ulti-
mate prevention and adequate control.
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
170
Prevention is a Prerequisite of a Good School
(1) Attendance at school by compulsion presup-
poses protection and safety for the pupil.
(2) Attendance is bettered in direct proportion
to the degree in which preventive measures are
carried out.
(3) Pupil health is essential to pupil progress at
school.
(4) A correct preventive procedure, rigidly en-
forced, demonstrates practically the principles and
rules studied by the pupils in health education,
thus serving to strengthen habits and attitudes.
Responsibility of Teachers
(1) The teacher has direct charge of the pupils
and the classroom.
(2) First contact with pupils at the opening
of the morning session is that of the teacher. It
is at this time that evidence of disease not present
at the close of the last school day should be de-
tected.
(3) The teacher is the only one of the school
staff in a position to observe pupils continuously
during school hours.
(4) Because of familiarity with the usual , ap-
pearance of his pupils, the teacher is enabled by
contrast to detect deviation from the usual or
normal.
(5) Preventive practices at school afford innu-
merable teaching situations by means of whic pu-
pils under guidance of the teacher may acquire de-
sirable habits and attitudes, and the knowledge
of prevention that will serve them in good stead
throughout life. The practices and the lessons to
be learned from them will each be stronger by
reason of coordination.
Program Necessary
Every school district should have a definite pro-
gram of procedures, standards, and policies de-
signed to meet local needs and to fulfill legal re-
quirements.
Care and precision should mark its preparation.
It should be complete in detail and scientific as to
recommendations. Ease of understanding is also a
prerequisite.
The program should be printed and given wide
publicity throughout the community as well as in
the schools. Its provisions should be classified
according to the staff members who will use it;
thus, “Standards for the Teacher”, “Standards for
the Janitor”, and so on, will be available.
Enforcement
Given a program, the school authorities should
take steps to insure absolute enforcement of all
provisions. Leniency at one point precedes a gen-
eral weakening of the whole.
Cooperation
(1) Of the board of health and the health offi-
cer. Maximum assurance of prevention and con-
trol depends to a large extent upon the degree to
which interest, purpose and program are held in
common by school and public health officials. That
part of the school program which relates to (a)
reasons for exclusion, (b) length of absence from
school, and (c) recovery and readmission, should
be formulated by the local health authorities.
Stated differently, the responsibility for preven-
tion and control within the school rests with the
educational authorities* while that concerning regu-
latory direction of the child outside of the school
belongs to the public health authorities. Coopera-
tion is necessary at several points as, for example,
in reciprocal reporting of cases and releases, in
immunization campaigns, in preparation and dis-
tribution of educative material, and in sanitary
measures.
(2) Of practicing physicians. In efforts to carry
on an effective program, it is essential that the
school have the good will and cooperation of the
physicians of the community. The school point
of view of maximum protection for the individual
and group, and of impartiality in conduct of its
program, should be made known. It should be in-
terpreted, and assistance in carrying it out re-
quested.
(3) Of the home. Schools should give publicity
to the reasons why children should be kept at
home. An annual form letter stating the common
indications of disease, and asking for cooperation
of the parents in preventing disease-spread, is one
effective way. All usual publicity methods should
be utilized.
When a child is reported as having a contagious
disease, the parents should be urged not to hasten
his return to school but to exercise extra precau-
tion lest the physical and nervous strain cause
more serious possible permanent harm.
Records and Reports
Operation of the program requires a correlated
system of records, notices, and reports. Like the
program, the forms and letters should be adapted
to local needs and conditions, although for the
most part there will be little need for variation.
State Health Department
PASTEURIZATION OF MILK
D. C. Bowen, Director New Jersey State Depart-
ment of Health
Pasteurization of milk and cream becomes more
important with the growth of cities and with the
necessity for procuring milk from greater dis-
tances. Milk may be contaminated with patho-
genic organisms on one farm, and contamination
is easily spread throughout an enormous quantity
of milk when such contaminated milk is mixed
with milk frofn several farms at the receiving
station.
Pasteurization of milk is the most effective
safeguard known against the possibility of spread-
ing typhoid fever, paratyphoid fever, scarlet fever,
septic sore throat, undulant fever, diphtheria and
dysentery through milk. Outbreaks of these dis-
eases continue to be traced to the consumption of
raw milk and only limited progress has yet been
made in preventing the spread of infection through
raw milk. Realizing that pasteurization of milk
should be carried on under standard and uniform
requirements in this state, the State Department
of Health adopted specific regulations governing
the construction and operation of milk pasteurizing
plants in 1917. These requirements have been
made more stringent from time to time until now
pasteurization of milk in the plants of this state
is carried on under rigid requirements.
Milk in the process of pasteurization is required
to be heated to a temperature of 142° to 145° F.,
and maintained at that temperature for a period
of 30 consecutive minutes. This temperature and
holding period allow sufficient margin of safety
over the minimum degree necessary for complete
destruction of possible disease-producing organ-
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
171
isms that might be spread by milk. Such margin
of temperature is always necessary in all commer-
cial pasteurization plants. Immediately following
the period of heating, the milk is required to be
cooled down to a temperature of 50° F. or below
and maintained at such temperature until delivered
to the consumer. Records of the temperature to
which milk is heated are required to be made by
recording thermometers, dated and filed at the pas-
teurizing plant for inspection by agents of the
State Department of Health. The accuracy of
these recording thermometers is to be checked daily
by the operator with an accurate indicating ther-
mometer. Gross inaccuracies in pasteurizing tem-
peratures seldom occur nowadays, as milk dealers
and operators are anxious to have their tempera-
tures check accurately. This is a protection not
only to the milk consumer but an advantage to
the milk dealer. The latter realizes that insuffi-
cient pasteurizing temperatures or time of holding
will call for severe criticisms of health depart-
ment representatives who are anxious to safe-
guard and consumers of milk, while too high tem-
peratures (above the usual pasteurizing range)
may react unfavorably upon the milk product by
interfering with cream-line, taste or other market-
able qualities.
Milk pipes and pipe fittings are required to be
disconnected and thoroughly cleaned after use.
Receiving and holding vats, coolers and bottle
filling machines must be built of metal or other
suitable material and provided with closely fitting
metal covers. Bottles, cans or other receptacles
for pasteurized milk must be thoroughly washed
and sterilized. Mechanical bottle filling and cap-
ping machines are required to be used in the bot-
tling of pasteurized milk.
Before a license is granted by the State Depart-
ment of Health to operate a milk pasteurizing
plant, assurances that these requirements will be
carried out must be given by the applicant. Me-
chanical imperfections in pasteurizing apparatus,
such as leaky valves, dead-ends in milk lines, are
becoming things of the past not only because of
the vigilance of health officials but through the
technical interest of dairy engineers and manufac-
turers. Capping of bottled pasteurized milk with
the hands is prohibited by the state pasteurizing
regulations. Cleanliness of equipment used in pas-
teurizing plants, such as the pasteurizing vats
themselves, receiving and storage vats, milk
pumps and pipe lines, filters, coolers, bottle-fillers
and cappers, is demanded at all times. Proper
cleansing of milk bottles, cans or other contain-
ers for milk also receive their share of attention
by inspectors. The department is firm in its be-
lief that pasteurization was never intended as a
substitute for cleanliness in milk production or
plant operation. The process is, and should be,
an added safeguard to milk that has been pro-
duced by clean, healthy cows, milked by clean
healthy milkers or clean milking machines, and
handled and cooled under clean, sanitary condi-
tions.
The department’s greatest need along the line
of increased supervision of pasteurizing plants is
the employment of additional inspectors to check
the various processes incident to proper pasteur-
ization and handling of milk more frequently than
is possible at the present time. Just as 2 salesmen
of equal ability and like traveling facilities can
cover more ground in less time than only 1, so 2
trained inspectors of equal capacity can accom-
plish more than 1 in the proper supervision of pas-
teurizing plants. r
The State Department of Health issues licenses
for the operation of pasteurizing plants without a
fee, after inspection by our agent proves that
the requirements of this department are fulfilled.
The oft-repeated inspections of pasteurizing plants,
including careful examinations into details of oper-
ation, which have been made by Agents of the State
Department of- Health and the local boards of our
larger cities since the law was passed in 1915,
account for the excellent condition of the plants
of this state and also for the efficiency with which
milk is pasteurized.
The number of plants pasteurizing milk has
increased steadily from 85 in 1915 to the present
total of 197. Most of the new plants are used for
the pasteurization of relatively small quantities
of milk in the smaller cities and towns. Inspection
of such small plants falls almost entirely upon
the State Department of Health, as the inspectors
of small communities generally lack the knowledge
and experience necessary to undertake such tech-
nical inspection.
Communications
FIFTEENTH ANNUAL CLINICAL SESSION OF
THE AMERICAN COLLEGE OF
PHYSICIANS
The Fifteenth Annual Clinical Session of the
American College of Physicians will convene in
Baltimore, Maryland, March 23-27, and In Wash-
ington, D. C., March 28, 1931. The organization
holds this session in Baltimore through the cor-
dial invitation of the Johns Hopkins University
School of Medicine, the University of Maryland
School of Medicine, the Medical and Chlrurgical
Faculty of the State of Maryland, the Baltimore
City Medical Society, and the further cooperative
interest manifested by the various Baltimore hos-
pitals and civic societies. Held in important medi-
cal centers, these Clinical Sessions constitute, per-
haps, the most important post-graduate week in
internal medicine each year. Those who attend
the meeting will find ample in the way of clinical,
laboratory, research and historic interest, well to
repay them for the time spent in making the
journey. Dr. Sydney R. Miller, of Baltimore, Presi-
dent of the American College of Physicians, has
prepared the program for the General Scientific
Sessions, while Dr. Maurice C. Pincoffs, General
Chairman, also of Baltimore, has arranged the
program of clinics, demonstrations and entertain-
ment.
As an added feature of the Clinical Session this
year, an additional day, March 28, will be spent in
Washington, D. C., where a special program of
clinics and inspection tours has been arranged
under the auspices of the Medical Departments of
the U. S. Army, U. S. Navy, U. S. Public Health
Service and Georgetown University. Dr. William
Gerry Morgan is acting as Chairman of the Wash-
ington Committee.
Hotel headquarters will be at the Lord Balti-
more Hotel, while general headquarters, at which
the registration of members, commercial exhibits
and all general sessions will be held, will be The
Alcazar, Cathedral and Madison Streets, Balti-
more. Transportation on the Certificate Plan of
reduced fares will be available to all physicians and
dependent members of their family from all parts
of the United States and Canada. A special pro-
gram of entertainment has been arranged for
visiting ladies. The Convocation for the induction
172
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
F eb., 1931
of new members, as Masters or Fellows, will be
held on Wednesday evening, March 25, and the
Annual Banquet will be held on Thursday even-
ing, March 26. The Business Meeting, at which
reports of administration and elections for the
new year will take place, will be held during the
forenoon of Thursday, March 26.
Mr. E. R. Loveland, 133-135 S. 36th Street,
Philadelphia, is the Executive Secretary of the
College, and it is to him that requests for further
information or programs should be addressed.
AMERICAN ASSOCIATION FOR THE STUDY
OF GOITER
(Announcement by the Secretary, Dr. J. R. Yung)
The American Association for the Study of
Goiter again offers an award of $300 for the best
essay based upon original research work on any
phase of goiter presented at its annual meeting in
Kansas City, Mo., April 7-9, 1931. It is hoped this
offer will stimulate valuable research work, es-
pecially in regard to the basic cause of goiter.
Competing manuscripts must be in the hands of
the Corresponding Secretary, J. R. Yung, M.D.,
Terre Haute, Indiana, not later than April 1, to
permit the award committee sufficient time to ex-
amine all data. Manuscripts arriving after this
date will be held for the next year or returned
at the author's request.
Woman’s Auxiliary
PANORAMIC VIEW OF THE WOMAN’S AUX-
ILIARY TO THE AMERICAN MEDICAL
ASSOCIATION
The Eastern District
Mrs. W. Wayne Babcock.
Philadelphia, Pa.
According to the Constitution of the National
Auxiliary, the First Vice-President is automatically
Chairman of Organization, the 3 other Vice-Presi-
dents being organizers for their sections of the
country. Mrs. Southgate Leigh, of Virginia, there-
fore, holds this chairmanship, and the Eastern
District is her particular responsibility. At her
request a series of 4 articles is being prepared by
her committee in order that each district may be
made better cognizant of the progress of its own
states. The individual state journals have been
extremely generous in the space allowed their
auxiliaries and this additional courtesy of report-
ing the auxiliary situation in other states is
deeply appreciated, for there is a growing desire
to know “what others are doing”.
New Hampshire stands alone as the only New
England state 100% organized and cooperating
with the national organization. Last year the
state auxiliary had misgivings as to its necessity
and usefulness but an urgent request from the
medical society that the women remain organized,
dispelled all doubts. During the year following,
Mrs. Hubbard, wife of the State Society President,
visited every county and encouraged and stimu-
lated the growth of unit auxiliaries.
The New Jersey Auxiliary members made pil-
grimages to state institutions, set apart one meet-
ing when the mothers of physicians were enter-
tained, and sponsored various health meetings.
The Essex County Auxiliary, assisted by the physi-
cians, succeeded in establishing a course of health
talks in cooperation with the Y. W. C. A., of New-
ark, emphasizing especially prenatal care and in-
formation which would aid the mothers of babies
and young children. Last year Mrs. James Hunter,
Jr., New Jersey’s State Auxiliary President, visited
every county, as did Mrs. Walter Jackson Free-
man, in Pennsylvania, during her presidency. One
cannot help drawing the conclusion that personal
contacts are necessary for county auxiliary de-
velopment and success.
Virginia is active in spots. The doctors en-
courage the auxiliaries because they believe that
through them education with regard to the menace
of state medicine can be spread.
Ohio for several years has been sending repre-
sentatives from a feu organized counties to the
national meetings but as yet there is no state or-
ganization. Our friend and adviser, Dr. Up-
ham, who lives in Ohio, it is felt will advise
the National Auxiliary when the auspicious time
arrives for establishment of a State Auxiliary.
The District of Columbia seems so completely
diverted by Washington affairs that the auxiliary
which so capably cared for the A. M. A. meetings
some years ago seems to have gone into retire-
ment.
Delaware, in a breathless, better-late-than-never
manner, has completely caught up and is most
interested and active, and has entered upon serious
work by assisting the physicians in establishing
a medical library in Wilmington. They will co-
operate with Philadelphia at the time of A. M. A.
Convention and the eastern section will introduce
them with pride to the National Organization.
West Virginia is up and doing and you may ex-
pect still better things from that state this year.
Maine, Massachusetts, Rhode Island, Vermont
and Maryland have reported some interest among
individuals but no organized effort. Queries from
different localities in New York, as to why there
is no auxiliary, have been answered with the state-
ment that several years ago the House of Dele-
gates voted unanimously in favor of the auxiliary
and authorized its organization, but nothing has
since been accomplished. The same year Connecti-
cut voted favorably but no definite steps have been
taken toward organizing.
Pennsylvania has surely discovered the rhythm
in which its auxiliary work is best done, for con-
crete accomplishments have been turned out regu-
larly, year by year. Of the $3000 contributed last
year to the Medical Benevolence Fund more than
two-thirds was contributed by the Auxiliary. A
definite trend toward educational meetings is felt
all over the state, and socially it is hoped that the
carefully formed Philadelphia plans for the next
meeting will bring honor and glory to the Keystone
State. Not only are the adult members of the
auxiliary meeting but a group of the most charm-
ing and good-looking daughters of doctors are
working together in order that they may come to
know each other and to work in unison for the
comfort and pleasure of the A. M. A. guests when
they come to Philadelphia in May. Verily, who
can question the wisdom of the auxiliary, when it
brings about so much willing work in behalf of
the medical men of the country?
ATTENTION LADIES!
The following brief article is quoted from the
Journal of the Indiana State Medical Association
and commended to our auxiliary members for con
sideration. We respectfully recommend that the
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
173
advice be taken; that is, that county auxiliaries,
as organizations and individual auxiliary members,
write to The Delineator expressing condemnation
of the use of its pages for such pernicious “health
talks".
Attention Ladies
In the September 1930 number of The Deline-
ator, Celia Caroline Cole presumes to give some
sage medical advice, and as treatment “for the
puffy look around the eyes and lines and wrinkled
lids”, among other things she says: “Eye exercises
— spectacles if you have to have them, but better
take the eye exercises and have a good osteopath
adjust the nerves in the back of the neck and
backbone and then dispense with spectacles." Fur-
ther on she says: “Use a nourishing cream on the
lines and a mild astringent on the puffiness. Learn
to rest your eyes by palming, or when you are out
in public and can't palm merely by thinking of
lovely things you have seen — feel the eyes relax
with pleasure — or by thinking of deep, deej), smoky,
floating, velvety black.”
Think of feeding such tommyrot to sensible
readers and imagine, if you can, how idiotic this
advice appears to many intelligent readers whether
they know much about scientific medicine or not.
Just how the proprietors and owners of The De-
lineator can square themselves after accepting for
publication such nonsensical stuff remains to be
seen, and it is more difficult to understand why
The Delineator permits its pages to be so prosti-
tuted. As a suggestion to the members of the
Woman’s Auxiliary of the American Medical
Association we recommend that each and every
one of them write a letter of protest to The De-
lineator, and accompany it with the request that
The Delineator make suitable amends or cancel
the subscription of the writer. Y'ou can bet a dollar
against a punched nickel that if even a few hun-
dred members of the Woman’s Auxiliary, with
their influence in women’s clubs, attack The De-
lineator for printing such untrustworthy informa-
tion as herein quoted, there will be a right-about-
face policy adopted by the publishers and owners
of The Delineator. Intelligent people do not want
their favorite periodicals to be dealing out false,
unscientific and untrustworthy articles concerning
the practices of medical pretenders, and if the
owners and publishers of The Delineator are wise
they will not have a repetition of articles such as
the one to which we refer.
STATE SOCIETY AUXILIARY
Reported by Mrs. W. Blair Stewart
Mrs. John Nevin, of Jersey City, President of
the Woman’s Auxiliary to the Medical Society of
New Jersey, presided at an open Executive Com-
mittee meeting on Monday, January 12, at noon,
in the Princeton Room of the Stacy-Trent Hotel,
Trenton; after which a most delectable luncheon
was served in the Roof Garden. There were present
representatives also from the auxiliaries to the
medical societies of Pennsylvania and Delaware.
Mrs. George N. J. Sommer, as Chairman of Ar-
rangements for the day, welcomed the assembled
guests in her usual charming manner and intro-
duced those who took part in the beautiful musi-
cal program. These were Mrs. D. Hartley Sinclair,
soprano, and Mrs. Charlotte Magill, pianist.
After the luncheon the president introduced the
main speaker of the afternoon, Mrs. Walter Jack-
son Freeman (daughter of the well loved and
eminent surgeon, Dr. W. W. Keen, of Philadel-
phia), who is Chairman of Arrangements for the
Auxiliary meeting with the American Medical
Association Convention June 8-12. Mrs. Freeman
stressed the point that this is to be a national and
not in any way a local affair — and that every mem-
ber from the hostess states is to be a real hostess
to every guest.
Another committee meeting was held to plan
for the State Medical Society Convention to be
held in Asbury Park during the first week of June
1931.
Preliminary Program
Woman's Auxiliary to the American 'Medical
Association
Ninth Annual Meeting
Philadelphia, June 8-12, 1031
Headquarters Bellevue-Stratford Roof Garden
(Every member must register in order to obtain
cards for the various social events at the Conven-
tion.)
Monday, June 8
12.30 p. m.
Luncheon to Presidents, 1922-31 . South Garden
Subscription
2-4.05 p. m.
Three Round Tables, 35 minutes each with 10 min-
ute intermissions North Garden
Subjects: (1) Program for County Auxiliary Meet-
ings.
(2) National Study Envelopes.
(3) The Technic and Value of Auxiliary
Contacts with the Community.
6.30 p. m.
Board Dinner, subscription Red Room
7.30 p. m.
Board Meeting . . Red Room
Tuesday, June 0
9 a. m.
General Meeting North Garden
Luncheon in South Garden (Bellevue Special).
2 p. m.
Bus Trip to Valley Forge with tea in Log Cabin.
Hostesses to be announced.
or
Boat Trip on Delaware with tea on board.
Hostesses to be announced.
8 p. m.
General Meeting of American Medical Association
10 p. m.
Supper Dance, subscription Rose Garden
Wednesday, dime 10
9 a. m.
General Meeting and Election . . North Garden
12.30 p. m.
Auxiliary Luncheon, subscription Rose Garden
Guests and Speakers from American Medical Asso-
ciation.
2.30 p. m.
Bus Trip through Historic Philadelphia, Fairmount
Park and Germantown with tea to be announced.
Host, American Association.
9-11 p. m.
Reception, to be announced.
Hostesses, Pennsylvania State Auxiliary.
1 74
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
Thursday, June 11
9 a. m.
Board Meeting Red Room
10.30 a. m.
General Round Table . . North Garden
Subject: What Have I Gotten Out of the Con-
vention?
Luncheon in Soutli Garden (Bellevue Special.)
2 p. m.
Bus Trip to be announced.
9 p. m.
President’s Ball.
Host, American Medical Association.
Friday, June 12
9.45 (?) a. m.
Trip to Atlantic City (special cars).
or
trip through Wanamaker’s with luncheon in Crys-
tal Tea Room.
All transportation paid by members.
Atlantic County
Reported by Mrs. Maurice Chesler.
The December meeting of the Woman’s Aux-
iliary to the Atlantic County Medical Society was
held on December 8 in the Blue Room of the Chal-
fonte Hotel at 8:30 p. m.
In the absence of our President, Mrs. J. T. Beck-
with, Mrs. John F. Massey presided.
Minutes of previous meeting were approved as
read.
In keeping with the holiday spirit, it was sug-
gested that the auxiliary spread Christmas Cheer
to the needy, and a motion was carried to donate
to the following:
Atlantic County Hospital for Tuberculous Dis-
eases: woolen gloves, socks, writing material;
Atlantic City Day Nursery: flat silverware; Betty
Bacharach Home at Longport: wash cloths; Muni-
cipal Hospital: woolen undergarments for chil-
dren; Santa Pals of Atlantic City: $10.
After the meeting cards were enjoyed.
January Session
The January meeting was held on January 9,
Mrs. J. T. Beckwith presiding.
In the absence of our Recording Secretary, Mrs.
Lawrence Wilson, the minutes were held over
until next meeting.
Letters of thanks were received from the Atlan-
tic City Day Nursery, Atlantic County Hospital
for Tuberculous Diseases, and from the Santa Pal
Fund, for donations received from the Auxiliary
during the Christmas holidays.
Tentative plans were made for a Card Party
for the benefit of patients of the Atlantic County
Tuberculosis Sanitarium.
Mrs. W. Blair Stewart, Mrs. John F. Massey
and Mrs. Samuel L. Salasin will represent Atlan-
tic County at the Executive Committee Meeting
of the State Auxiliary in Trenton. Several of our
members will also attend the Tea to be given by the
Camden County Medical Society Auxiliary.
Motion was made to send plants to Mrs. Mark
J. Haley and Mrs. Lawrence A. Wilson, who are ill.
Motion was also carried to accept with regret the
resignation of Mrs. William Martin.
Camden County
Reported by Mrs. A. J. Casselman
The Woman’s Auxiliary to the Camden County
Medical Society entertained its neighboring clubs
and county auxiliaries January 13 at a very de-
lightful reciprocity meeting at the Camden
Woman’s Club House, 424 Linden Street, Camden.
The meeting was filled with a fine spirit of hos-
pitality and cooperation. It was presided over by
the president of the auxiliary, Mrs. Arthur J. Cas-
selman, who extended a cordial greeting to the
guests.
Mrs. A. Haines Lippincott, the Program Chair-
man, made a strong plea for aiding the helpless,
those in dire need, and to do everything to give
work to the unemployed. She then introduced the
speaker of the afternoon Dr. Francis Harvey Green,
of the West Chester State Normal School. His sub-
ject was "The Spirit of Inquiry”. The main points
taken were: "How are you? How do you do? Are
you agreeable to live with? and What are you
good for?” Dr. Green is always a most interesting
and amusing speaker; no naps are taken!
Mrs. Wralter Jackson Freeman, Chairman of the
Auxiliary Entertainment for the American Medi-
cal Association Convention, spoke very effectively
of the program as arranged and of the duties of
the hostess states.
All New Jersey members are to be co-hostesses
with those of Pennsylvania. Mrs. .T. Newton Huns-
berger, of Norristown, Pa., President of the Na-
tional Auxiliary, brought a greeting. She spoke
earnestly of the work of the county society, and
how there could not be national work without the
work of the state society; neither could there be a
state society without the work of the county so-
ciety, which is the foundation stone.
Essex County
(A note from Mrs. McCauley)
The County Society Auxiliary has planned a
Theatre Party for the benefit of its scholarship
fund, to be held at the Lyceum Theatre, East Or-
ange, on the evenings of February 16 and 17. The
guest star will be Miss Margaret Anglin. Look
out for advertisement of the event, giving full par-
ticulars.
Passaic County
Reported by Mrs. Richard J. McDonald
The Woman’s Auxiliary to the Passaic County
Medical Society held the first meeting of this year
at the Paterson Woman's Club, Thursday after-
noon, January 15, at 2.30 p. m.
The President, Mrs. William Neer, presided. A
most interesting and instructive program was
furnished by the following speakers: Mrs. James
F. Radcliffe. President of the Children’s Day
Nursery, spoke on “The Care of Day Nursery
Children”. Miss Anna McGeachie, Supervisor of
Speech Defect Department in Paterson Schools,
spoke on “Corrective Speech”. Miss Elizabeth K.
Watson. Supervisor of Special Classes in the City
of Paterson, spoke of “Backward Children”.
Each speaker explained her particular line of
work and brought to the listeners’ minds the dif-
ferent agencies which are constantly at work to
improve the lives and opportunities of the less
fortunate children, socially, physically and men-
tally.
The meeting was largely attended.
Following these talks, tea was served and a
social hour enjoyed.
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
175
Somerset County
Reported by Mrs. Dan Renner
The Woman’s Auxiliary to the Somerset County
Medical Society held its second meeting at the
Nurses’ Home of the Somerset Hospital, Decem-
ber 13, 1930. The minutes of the previous meeting
were read and approved. Mrs. Renner reported
the receipt of several new subscriptions to Hygeia.
This means an addition to the funds in the treas-
ury.
The duly elected officers for this year are: Presi-
dent, Mrs. C. R. Kay, Peapack; Vice-President,
Mrs. J. Meigh, Bernardsville; Treasurer, Mrs. E.
Flint, Raritan; Corresponding Secretary, Mrs. D.
Renner, Skillman; Recording Secretary, Mrs. L.
Ely, Somerville: Reporter, Mrs. A. Levy, Somer-
ville.
A motion was adopted that a card party be held
in the near future to raise funds for our share of
the entertainment at the next A. M. A. Conven-
tion.
The women, upon adjournment of their own
meeting, were invited to join the men in viewing
motion pictures issued by the Petrolagar Labora-
tories. At the close of the meeting, Mrs. Daisy
Kingston, Superintendent of the hospital, served
delicious refreshments. Altogether, it was an en-
joyable meeting and an afternoon well spent.
Union County
Special Meeting
Reported by Mrs. H. V. Hubbard
A committe of members attended a luncheon Jan-
uary 9 at the home of the President, Mrs. H. V.
Hubbard, in Plainfield, and plans were made for
programs and work for the current year.
The resignation of the Secretary, Mrs. Russell
Shirrefs, of Elizabeth, was read. This will be
acted upon at the next meeting when her suc-
cessor will be appointed.
The next regular quarterly meeting will be held
in the Nurses’ Home of the Elizabeth General Hos-
pital, Wednesday evening, January 14, when mat-
ters of great importance wTill be considered.
Mrs. Russell Shirrefs will be the speaker. Her
subject will be “Making a Small Garden”.
Regular Meeting
Reported by Mrs. M. M. Hoffman
The regular meeting of the Woman’s Auxil-
ary to the Union County Medical Society was
held in the Nurses’ Home of the Elizabeth Gen-
eral Hospital, Elizabeth, Wednesday evening, Jan-
uary 14, Mrs. Hubbard, President, in the chair.
Mrs. McElhinney, Treasurer, reported balance
on hand of .$100.96.
The resignation of Mrs. Shirrefs as Secretary
was read and accepted with regret. Mrs. C. A.
Hoffman, of Plainfield, was elected Secretary to
fill the unexpired term of Mrs. Shirrefs. Mrs. H.
Johnson, of Plainfield, was elected Assistant Secre-
tary for the same period.
Mrs. Schliehter’s letter of appreciation and
thanks for flowers received during her recent ill-
ness was read and accepted.
Mrs. Shirrefs moved that the following program
read by Mrs. Hubbard be accepted and carried out.
Motion seconded and carried.
On February 16 a luncheon at the Winfield Scott
Hotel in Elizabeth, when Mrs. John Nevin, of
Jersey City, State Auxiliary President, and Mrs.
H. Roy Van Ness, of Newark, President-Elect, will
speak and be guests of honor.
In March, a luncheon and card party to be held
in Plainfield.
April — Regular Quarterly Meeting will be held
with Book-Review following.
May — Dinner and entertainment with the mem-
bers of the Union County Medical Society as guests
of honor.
June — State Medical Society Convention at As-
bury Park and the A. M. A. Convention at Phila-
delphia.
July- — Last quarterly meeting of the year.
Mrs. George L. Orton, of Rahway, gave a report
on the mid-winter luncheon and meeting of the
State Auxiliary Executive Committee held in
Trenton last Monday. She also reported the many
attractive features of the program being planned
by the auxiliaries of Pennsylvania, New Jersey and
Delaware to entertain the National Auxiliary dur-
ing the sessions of the American Medical Associa-
tion in Philadelphia in June.
Mrs. Shirrefs’ talk on “How to Make a Small
Garden” -was postponed until a spring meeting.
A door prize was won by Mrs. Bunting, of Eliza-
beth.
Refreshments were served in the company of
the Union County Medical Society in the dining
room of the hospital.
County Society Reports
ATLANTIC COUNTY
John S. Irvin, M.D., Reporter
The regular monthly meeting of the Atlantic
County Medical Society was held Friday evening,
January 9, at the Hotel Chalfonte, Dr. Norman J.
Quinn presiding.
A motion was passed to reconsider the offer of
the Dawley Collection Agency, which was tabled
at the last meeting, and to instruct the president
to appoint a committee to investigate the offer;
Drs. Scanlan, Shivers and Carrington were ap-
pointed.
The Secretary announced that an application for
membership had been received from Dr. Joseph
Smurl. This was referred to the Board of Censors.
A letter from Dr. Reik was read concerning a
renewal of post-graduate study sponsored by the
State Society and Rutgers University. It is pro-
posed to offer courses on numerous subjects of
interest to the general practitioner and the special-
ist. The president appointed the same committee
which had this matter in charge last year to make
whatever arrangements it deems wise; Dr. Car-
rington is chairman of this committee.
Communications were read from Senator Rich-
ards and Assemblymen Siracusa and Altman, in
reply to letters sent them embodying the protest of
this society against the proposed changes affect-
ing the State Board of Medical Examiners. As-
semblyman Siracusa said he would give the mat-
ter his attention. Assemblyman Altman said he
■would do everything he could. Senator Richards
refused to comply with the wishes of the society
and stated his reasons.
The first paper on the scientific program was
‘Leukorrhea — Its Significance and Treatment”, by
Dr. P. Brooke Bland, Prof, of Obstetrics, Jefferson
176
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
Medical College. As Dr. Bland was confined to his
bed by illness, his paper was read by Dr. Leopold
Goldstein of the Department of Obstetrics, Jeffer-
son Hospital. (To be published later.)
The next paper was read by Prof. David H.
Wenrich, of the Department of Zoology, University
ol Pennsylvania, on “The Morphology of Trich-
omonas Vaginalis as Found in Leukorrhea”.
Dr. Wenrich said:
The study of Trichomonas vaginalis from a bio-
logic point of view requires that we determine not
only its morphology, but also its mode of life,
method of reproduction, and relation to other
species found elsewhere in the human body and
to species found in other animals. The micro-
organism shows the characteristics common to
tiichomonad flagellates in general: fusiform body,
whip-like flagella attached to the anterior end!
an undulating membrane along one side, .and an
axostyle protruding posteriorly. This species is
the largest of the trichomonad flagellates found in
man, varying from 10 to 30 microns in length in
the living state. It has 4 anterior flagella; a
relatively short undulating membrane, accom-
panied by a chromatic basal rod, usually not ex-
tending much beyond the middle of the body; a
rather large and elongated nucleus; and a para-
basal apparatus consisting of a sausage-shaped'
parabasal body and longer parabasal fibril. The
paiabasal body is rendered visible only after special
methods of staining. The organism multiplies by
binary fission. No true cysts have been found
although rounded-up stages which may persist for
1-2 days have been seen.
Trichomonas luccalis, found in the human
mouth, resembles T. vaginalis but is usually much
smaller, ranging from 6-12 microns in length
It lias 4 anterior flagella, an undulating membrane
slightly longer than that in T. vaginalis, a nucleus
that is commonly smaller and more deeply stain-
ing, and a parabasal apparatus similar to that of
/ . vaginalis but with a much shorter or biscuit-
shaped parabasal body, and there are fewer chro-
matic granules in the protoplasm.
In contrast to these species, Pentatrichomonas
at din delteili of the intestine is intermediate in
size and has 5 anterior flagella; a group of 4 and a
single one attached to a separate smaller blepharo-
plast. It also has a full-length undulating mem-
brane and chromatic basal rod, a trailing flagel-
lum and a larger cytostome. The protoplasm
usually lacks the chromatic granules seen in the
other species and no parabasal apparatus has
been found. It should be emphasized, therefore,
that Trichomonas vaginalis and T. buccalis re-
semble each other much more than either re-
sembles this intestinal form. Hence, it does not
seem reasonable to believe that the vaginal form
is derived from the intestine, as is commonly sup-
posed.
In literature. Trichomonas hominis, with 4 an-
terior flagella, is generally described as occurring
in the intestine, but in the present study all of
the 15 available cases of intestinal trichomoniasis
had flagellates corresponding in body morphology
to that of Pentatrichomonas, although the flagella
could not be counted in all cases. It is, therefore,
suggested that Pentatrichomonas is the common
form in the intestine and that Trichomonas hom-
inis is the same species in which one flagellum has
heretofore been overlooked.
Recently, Cleveland has described a new species.
Tritrichomonas fecalis from the intestine of man.
1 his has thus far been found in but a single human
subject. It resembles so closely a species of Tri-
trichomonas found in frogs and toads that one is
led to inquire as to whether a parasite of a cold-
blooded host may become a facultative inhabitant
of the human digestive tract. This possibility is
being investigated.
These papers were discussed by Drs. Carrington,
Darnall, Barbash and Kilduffe. Following discus-
sion, Dr. Goldstein and Prof. Wenrich demon-
strated live cultures of Trichomonas vaginalis
under the microscope.
Atlantic City Hospital Staff
Joseph H. Marcus, M.D., Secretary
The meeting of the General Staff of the Atlan-
tic City Hospital was held December 26, 1930, in
the Nurses’ Auditorium, and was called to order
by David B. Allman, President.
l)r. C. H. deT. Shivers, Chief of the Urologic
Department, gave a report of the past 12 months.
On account of our excellent results in a field of
surgery that deals mostly with the aged and poor
risks, we submit this report to you with a great
deal of satisfaction. The Urologic Service in the
Atlantic City Hospital, we are proud to say, is
growing. In the past we did half or more of our
surgery in the Atlantic City Genito-Urinary
Clinic; we are now doing all the so-called clean
work in the Atlantic City Hospital, leaving only
those cases complicated by active venereal infection
for operation in the Atlantic City Genito-Urinary
Clinic.
It is highly important in so complicated a
specialty as urology to have the surgical branch
in a hospital with a well equipped laboratory, x-ray
and other departments. For example, it is impos-
sible to make an accurate diagnosis with the cysto-
scope of diseases involving the upper urinary tract
without the aid of x-rays. Radiography is so
important that a pyelogram should be made in
every case where a thorough study of the kidney
and ureter is indicated. A ptosed kidney, calculus,
kink, strictures, dilated ureter, or kidney tumor
can be found by this method.
We constantly strive to improve the technic of
our prostatic operations and are giving more care
to pre-operative and postoperative treatment. We
constantly keep in mind the danger of hemor-
rhage following enucleation of the gland and are
prepared to control it so far as humanly possible;
and in doing so we save lives that otherwise would
be lost. Hemorrhage per se is not the direct cause
of death in the majority of cases, but indirectly it
plays a major part. In cases where the bleeding
is thoroughly controlled before the bladder is
closed there is a much greater chance for recovery
and a rapid convalescence. It is a dangerous pro-
cedure to close the bladder after enucleating the
prostate if there is even a little bleeding, without
first ascertaining the patient’s systolic blood pres-
sure; especially important in cases that show a
high pressure prior to operation. It is not un-
common for the systolic pressure to drop 40 to
60 mm. Fig. during the operation, and in such
patients very little if any bleeding will follow re-
moval of the gland. However, it is extremely im-
portant for the surgeon to take precautions to
control the subsequent hemorrhage which is sure
to follow when the blood pressure rises. We are
using the Pilcher modification of Hagner’s bag,
which allows the surgeon to make pressure for
control of hemorrhage, or release it at his will.
Another important factor in control of hemor-
rhage is suturing of the posterior lip of the blad-
der outlet, from 3 to 9 o'clock, using a continuous
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
177
00 plain catgut suture. This takes in the pros-
tatic capsule, torn internal sphincter, and mucous
membrane of the bladder. It is often necessary
in cases that bleed severely to place mattress
sutures on either side of the bladder outlet from
3 to 5 and from 9 to 7 o’clock, but this method of
suturing will control troublesome arterial bleed-
ing.
Our report comprises a list of 50 operations with
only 1 death, making a mortality rate of 2%. When
we review the type of cases operated upon and
their complications we feel that this is a low mor-
tality rate. Suprapubic prostatectomies head the
list; 11 consecutive operations without a single
death. It was necessary in 2 instances to do a
two-stage operation ; in the first because it was
impossible to pass a catheter through the urethra
to relieve an acute retention, and in the second be-
cause of hyperacute infection of the bladder.
Next on the list are 8 suprapubic cystostomies;
2 were done preliminary to a second stage supra-
pubic prostatectomy and 1 preliminary to removal
of stone in a urethral diverticulum in a female
patient; 2 for removal of vesical calculus and 3 for
figuration of carcinoma of the bladder and im-
plantation of radon seeds. A very interesting case
was that of the colored female who was trans-
ferred to us from the Gynecologic Service, with
a large diverticulum of the urethra which con-
tained a rather large uric acid stone. Suprapubic
cystostomy was done to divert the urinary stream
and prevent subsequent vaginal urethral fistula;
later, the stone was removed and diverticulum
resected. The suprapubic sinus was allowed to
heal and she lias made a complete recovery.
Other operations included 2 hydroceles; 1 vari-
ocele; 5 orchidectomies; 3 epididymectomies, and 5
perineal cystostomies.
Dr. Charles Bossert, Associate, presented a brief
resume of the work performed in the Genito-
urinary Clinic during 1930:
Syphilis, new cases
. male
152
female
132
total
284
Gonorrhea, new cases
male
20S
female
15
total
223
Treatments given
Syphilis
male
2522
female
2898
total
5420
Gonorrhea
male
2117
female
148
total
2265
Blood Wassermann
869
Dark fields
14
P. and V. and LT. smears . .
258
Spinal Wassermann
11
Cystoscopic examination
25
Adenotomv ...
12
P. and V. injections. Iodin per rectum 6
Bartholin abscess opened 1
Peri-urethral abscess drained 2
Venereal warts fulgurated 2
Dr. M. II. Axelrod presented a cystoscopic report
totaling 102 cases, with classification of conditions
found.
Before reporting a special case, I wish to discuss
briefly the history of tumors of the bladder. Until
the last century, tumors of the bladder were com-
pletely ignored by surgeons; until the end of the
fifteenth century, no mention of their existence
was made by any authors. Finally, near the end
of the sixteenth century, there appeared the first
mention of excrescences of the bladder, and many
theories were put forward in explanation. The first
work on tumors of the bladder was published by
Lacuna in 1551. The diagnosis was principally
made from symptoms of painful and difficult urina-
tion. For 200 years following Lacuna very little
progress was made in knowledge of vesical tumors;
very little was added either to the method of diag-
nosis or treatment until the eighteenth century,
though some ingenious instruments were devised
to give relief to such unfortunate patients.
Civalle and others began in the nineteenth cen-
tury to practice operative procedures on these
tumors through the suprapubic region. With in-
vention of the cystoscope came a rapid develop-
ment in early diagnosis, study and treatment of
vesical tumors. Dr. John T. Geraghty stated that
in looking over the records of the Johns Hopkins
Hospital from 1885 to 1896 it was interesting to
note that no case of tumor of the bladder was
admitted to the wards in which a diagnosis was
made sufficiently early to warrant anything more
than suprapubic drainage. It is probable that the
early records of other large hospitals will show
the same sad series of inoperable tumors of the
bladder. With development of. the cystoscope and
knowledge of the importance of investigating ap-
parently innocent hematuria, a new era arose.
Nitze, in 1896, reported a large series of cases in
which he had succeeded in completely eradicating
the tumors by his ingenious operating cystoscopes.
The endovesical treatment of bladder tumors did
not receive any particular encouragement until
Beer, in 1910, reported a method of treating papil-
lomas by high frequency current. More recently
the addition of radium to our therapeutic arma-
mentarium promises even more encouraging re-
sults.
Case Report. J. K., aged 65, colored, was thrown
from a truck Oct. 17, 19 30, and sustained a con-
tussion of the neck and spine. He gave history of
hematuria for 9 months.
Laboratory reports: Urinalysis, 5 mgm. percent
albumin and an occasional leukocyte. Blood chem-
istry— marked secondary anemia. Wassermann and
Kahn, both plus 4.
X-ray report: No evidence of fracture of the
upper cervical spine or skull.
Cystoscopic diagnosis: Multiple pedunculated
papillomas, with short pedicles, on the right side of
posterior wall of the bladder a short distance from
the base. Some enlargement of the lateral and
median lobes of the prostate. He was referred to
the Genito-LTrinary Clinic for antiluetic treatment
prior to operation. He was readmitted 4 weeks
later for operation. Under spinal anesthesia, the
entire area was destroyed in one sitting, using the
bipolar current. Since operation he has been free
of bladder symptoms and is now continuing anti-
luetic treatment at the clinic.
Dr. D. C. Reyner reported a case of “Urogenital
Tuberculosis”. C. G., white, male, aged 46, was ad-
mitted Sept. 15, 1930, complaining of great diffi-
culty in urination. He had been under treatment
at Pine Rest in June for pulmonary tuberculosis
and remained there for 28 days. Since October 1929
he has lost considerable weight; has had frequent
colds, some of these accompanied by high fever,
chills, sweats and severe malaise. Has been stead-
ily getting worse and in September 1930 began to
complain of frequent and difficult urination. On
September 15 he had an acute, complete urinary
retention and collapsed in a faint. Relief of his
abdominal pain and distress was obtained by
catheterization.
Examination of the chest showed an advanced
active pulmonary tuberculosis involving both
upper lobes. Examination of the external genitalia
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
1 78
showed a markedly enlarged, and quite painful and
tender epididymis on the right side. Rectal ex-
amination showed the prostatic gland enormously
increased in size; felt to be smooth, slightly irregu-
lar in outline, but firm and elastic and without
any evidence of malignancy or fluctuation.
The patient wore a retention catheter for 3
days, after which he was able to void with fail-
ease. At this time an area of fluctuation was noted
at the lower pole of the right scrotum and in-
volved the tail of the right epididymis. On Septem-
ber 21 the area was incised, under novocain anes-
thesia, and a large amount of foul smelling pus
escaped under pressure; smears from this pus
showed numerous tubercle bacilli. A radical epi-
didymectomy was not done in this case because
of the generalized tuberculous condition existing;
and, further, the opposite side would later have
become involved anyway — such infection extending
across the prostate which in these cases acts as
a bridge.
Until discharged from the hospital, 12 days after
admission, he made some progress. There was
still a discharging sinus present where the epi-
didymal abscess had drained, the prostate was still
very large and there was a beginning small soft
area palpable on the right side, but he was anxious
to go home and since he w-as able to void with ease,
with the exception of some burning and pain, he
was permitted to leave the hospital with instruc-
tions to return in a week. The following day he was
readmitted with complete urinary retention. Follow-
ing a catheterization, examination showed no
change except a greater area of softening in the
right lateral lobe of the prostate. Prostatotomy was
done under spinal anesthesia. It wras most difficult
in this case, because we were unable to elevate the
prostate forward or to make use of retractors to ex-
pose the base of the gland, because of very dense
adhesion. The prostatic urethra was opened, which
we are always able to avoid in cases not complicated
by tuberculosis. Following evacuation of the pus a
small fenestrated rubber tube was inserted into
the lobe, brought out through the perineum, and
sutured to the skin. We were unable to demon-
strate tubercle bacilli in the prostatic abscess, but
feel certain that it was a tuberculous abscess be-
cause in the existing conditions it was anatomically
impossible for the prostate to escape involvement.
The patient is still at the Municipal Hospital and,
although improved generally, still complains of
some pain in voiding, pain in his perineum and
occasional difficult urination.
BERGEN COUNTY
Charles Littwin, M.D., Reporter
The regular meeting of the Bergen County Medi-
cal Society was held at the Hackensack Hospital
Januai \ l.,, with Dr. E. \\ . Clarke in the chair.
Report of the Executive Committee was read by
Dr. Snedecor. On December 30, Drs. Clarke, Sarla,
Bittwin, Vroom, Payne, James and Snedecor met
at the home of Dr. Vroom, in Upper Saddle River.
The annual report of the Treasurer was read by
Dr. Sarla, showing a balance on hand, Jan 1
1931. of $2974.73.
^ The application of Dr. Lyman Burnham, of
Tenafly, for transfer from Kings County Medical
Society, was approved.
Dr. Morrow reported, as chairman of the Public
Relations Committee, the recommendation that
the Secretary should write to the State Board of
Medical Examiners requesting an investigation of
Dr. D. F. Haagen, of Hackensack. This was ap-
proved.
Dr. Payne brought up for discussion Senate Bill
304, proposed by the Abell Commission, to recog-
nize the licensing of all the professions. The con-
sensus of opinion is that this would be of real detri-
ment to the medical profession. The secretary was
asked to explain the provisions of the bill clearly
in the next issue of the Bulletin.
The committee then discussed the expense of
secretarial work, which has been mounting steadily
since publication of the Bulletin and increase in
activities of the society. It was recommended
that the society vote Dr. Snedecor $50 to cover
incidental expenses of the past 2 years and that
the society appropriate annually, the sum of $100
for expenses of the secretary's office.
Dr. McGilvery withdrew his application for
membership, because he is leaving Bergen County.
Dr. Payne stated that the Ridgewood Medical
Society felt that its members would have more
interest in the Bergen County Society, in which
only a few are members, if more of the meetings
were held nearer Ridgewood.
An informal discussion on committee appoint-
ments for the coming year was held. If any of
the members desire to do active work on any com-
mittee, the incoming officers will probably be only
too glad to appoint them.
Election of officers was then held, with the fol-
lowing results: President, Joseph R. Morrow; Vice-
President, Walter Schmidt; Secretary, Spencer T.
Snedecor; Treasurer, Michael Sarla; Reporter,
Charles Littwin; Delegate State Nominating Com-
mittee, A. Liva; Delegates for 3 years, Joseph
Payne, Herman Trossbach and Spencer T. Snede-
cor: Alternates, Conde de S. Pallen, Harrison B.
Wilson and Joseph Van Dyke.
With a very witty speech, Dr. CleCrke handed
over the President’s gavel to Dr. Morrow and
the latter received it with a bit of very sincere
oratory.
The scientific part of the meeting was then taken
over by Dr. Littwin who had prepared a “Sym-
posium on Sinus Disease", as follows:
“Anatomy and Physiology of the Sinuses”, Dr.
Simon L. Ruskin, Post-Graduate Hospital, New
York City.
“Sinusitis in Children”, Dr. William Greenfield,
Hackensack.
“Surgical Treatment of Sinusitis”, Dr. George
Worcester, Englewood.
“Conservative Treatment of Sinusitis”, Dr.
Charles Littwin, Palisade.
After some general discussion the meeting was
adjourned at 11:30 p. m.
CAMDEN COUNTY
R. S. Gamon, M.D., Reporter
The January meeting of the Camden County
Medical Society was held Tuesday, January 6, at
9.30 p. m.. Dr. W. J. Barrett, the new President,
presiding for the first time.
The Scientific Program consisted of a paper read
by Dr. Wesley Jack on “Diagnosis and Treatment
of Fractures of the Skull”, and discussion was
opened by Dr. A. S. Ross. The second scientific
paper was read by Dr. Vincent Del Duca upon
Management of the New-Born”. This paper was
discussed by Drs. E. G. Hummel and A. B. Davis.
The Committee on the Post-Graduate Extension
Work, Rutgers University, reported that Camden
County is to combine with Gloucester and Burl-
ington Counties in subscribing to a series of 8
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
179
lectures; 4 to be on Gastro-Intestinal Diseases and
4 on Cardio-Renal Conditions.
The society referred to the State Society Wel-
fare Committee a suggestion from one of the local
newspapers concerning paid educational advertise-
ments which were to be run in series.
The February meeting will be the annual Case
Report Night, which was one of the most popular
and well attended of all meetings last year.
Drs. Samuel C. Rosen, of 109 S. 27th Street,
Camden, and Harold P. Coxson, of Laurel Road,
Stratford, were elected to membership.
There were 61 members in attendance.
CUMBERLAND COUNTY
E. S. Corson, M.D., Reporter
Dr. Reba Lloyd, of Bridgeton, presided at the
meeting of the Cumberland County Medical So-
ciety January 13, at the Weatherby House, Mill-
ville, being the second woman physician to fill the
office of President of the organization, so far as
is known. Dr. Lloyd, who was elected Vice-Presi-
dent at the annual meeting, succeeded to the presi-
dency upon the death of Dr. Cornelius S. Franckle,
late of Millville. The first woman physician to
fill the office of president was Dr. Mary Dunlap,
at that time residing in Vineland. This was ap-
proximately a quarter of a century ago.
The following members were elected: Drs. Charles
Cunningham, Vineland; G. A. Davies, Elmer;
Charles B. Neal, Millville; H. Burton Walker, Vine-
land; F. Vernon Ware, Millville. Dr. Frank Shep-
pard, of Millville, was elected Vice-President.
Dr. W. Hersey Thomas, of Temple University,
discussed the subject of Intravenous Urography.
Previously, in order to obtain an x-ray picture of
the urinary tract, it was necessary to introduce
an instrument into the urinary bladder and illu-
minate it, by which means the mouths of the
ureters were found and a tube introduced, through
which a stain was forced into the kidney, making
it impermeable to x-rays, and thereby outlining
the anatomy and any foreign body therein. Re-
cently a new method has been devised, whereby
the stain is introduced into a vein and in a few
minutes the entire urinary tract may be outlined.
This method obviates the inconvenience and dis-
comfort of instrumentation and its attendant risks.
Many x-ray pictures were shown illustrating both
methods and the comparative results.
Dr. John O. Bower, of Temple University, dis-
cussed “The Management of Toxic Goiter”. There
are several forms of goiter which affect the health,
each form representing different stages and changes
of the diseased condition. There are 3 methods of
treatment, operative, x-ray and radium. Selection
depends upon the character and progress of the
disease in its effect upon the patient. A basal met-
abolism test should be taken to determine the
degree of oxygen expended to maintain chemical
changes in the body. Children as young as 1
year were shown as being affected, and good re-
sults were obtained by transplanting parts of
goiter from another person. Medical treatment
affords but little permanent good.
ESSEX COUNTY
E. LeRoy Wood, MD., Reporter
A meeting of the Essex County Medical Society
was held in Newark at the Academy of Medicine
Thursday evening, January 8, with Dr. Henry C.
Bark horn, the President, in the chair. About 100
members attended.
“Will Vocational Training of Pupil Nurses Help
the Physician?” was the title of an address by
Dr. Edgar A. Ill, who is a member of the Newark
Board of Education, in which he advocated a plan
of providing vocational training in primary sub-
jects to relieve hospitals of the burden of so
much time devoted by pupil nurses to class-room
lectures. On motion it was voted to approve Dr.
Ill's suggestions, and to direct the attention of hos-
pital and training school authorities to serious
consideration of the subject. Discussion was par-
ticipated in by Drs. Hagerty, Polevski, Haussling,
Bingham, Stahl, and Buermann.
“The Doctor and the County Health Movement”
was the title of an address by Mr. Wm. J. Orch-
ard, President of the Essex County Health Council,
and also of the Chamber of Commerce of the Or-
anges and Maplewood. He outlined the plans of
this Council in coordinating the health activities,
preventive and curative, of all the hospitals, clinics,
charities, medical organizations and governments
in the 22 municipalities in this county; a compre-
hensive outlook taking probably 5 years to accom-
plish, and having in view reduction of costs and
increase in efficiency of county health work. Dis-
cussion with questions and answers followed. Drs.
E. J. Ill, Rubinow, Bradshaw, Polevski, Pinneo,
Bingham, .Jackson and Rev. Mr. Martin, Superin-
tendent of St. Barnabas Hospital, took part. A
rising vote of thanks to Dr. Ill and Mr. Orchard
was passed.
Dr. Barkhorn entertained the speakers and the
society officers at dinner before the meeting.
Eye, Ear, Nose and Throat Section Academy of
Medicine of Northern New Jersey
E. LeRoy Wood, M.D., Secretary
The regular monthly meeting of the Eye, Ear,
Nose and Throat Section of the Academy of Medi-
cine of Northern New Jersey was held on Mon-
day evening, December 8. The paper of the even-
ing was read by Dr. H. B. Orton, of Newark, de-
scribing several cases of mediastinal infection
secondary to foreign bodies in the air or food pas-
sages. With the aid of lantern slides and diagrams
he fully described this serious condition, the anat-
omy of the region, and the pathways of infec-
tion. He then discussed the surgical approach and
the general management, from the standpoint of
the bronchoscopist and the thoracic surgeon.
In discussion, Dr. Dieffenbach, who had co-
operated in treatment of one of the patients who
recovered, pointed out that posterior mediastin-
otomy is not so formidable and shocking as it
seems.
Dr. Wallace Pyle, of Jersey City, presented a
case of “Bilateral Progressive Blindness”, first
in one eye and then in the other, following a series
of head injuries.
The meeting adjourned at 10.15 p. m. Forty-two
were present.
GLOUCESTER COUNTY"
Henry B. Diverty, M.D., Reporter
The epidemic of grippe and colds held down at-
tendance at the monthly meeting of the Gloucester
County Medical Society at the Hotel Pitman
ISO
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
January 15. Those attending from this county in-
cluded Dr. I. W. Knight, the President; Drs. M.
F. Lummis, Pitman; Charles Pedrick, Glassboro;
A. B. Black, Mickleton; C. F. Fisler, Clayton; S.
F. Ashcraft, Mullica Hill; Ralph Hollinshed, West-
ville; Duncan Campbell, Woodbury; George N. J.
Sommer, President of the State Medical Society;
Howard F. Palm and Emma Richardson, of Cam-
den County; Carroll Rogers, of Swedesboro.
The essayist, Arthur D. Goldhaft, V. M. D., of
\ ineland, chose as his subject, “Diseases Common
to Man and Animals”, which was greatly enjoyed
by those attending.
A fine dinner was served by the Hotel Pitman
managers.
HUDSON COUNTY
E. G. Waters, M.D., Reporter
The regular meeting of the Hudson County Medi-
cal Society was held at the Carteret Club January
6, with the President, Dr. J. M. Cassidy, presiding.
The president announced that the Annual Din-
ner is to be held on the first Saturday after Easter,
at the Carteret Club, Jersey City.
The Publicity Committee reported that several
conferences had accomplished nothing as yet. A
verbal resignation of the chairman of this com-
mittee was offered by the Secretary.
Dr. Wm. N. Barbarito, reporting for his com-
mittee, stated that the new constitution would be
ready for consideration at the February meeting.
Post-Graduate Committee. Dr. Louis Lange re-
ported progress and stated that plans are under
way for several courses.
The resignation of Dr. Earle Creveling was ac-
cepted with regret.
The following new applications were received
and referred to the Board of Censors:
Drs. Wm. C. Sehuchner, 264 First Street, Jersey
City; Morris Green, 476 Palisade Avenue, Wee-
liawken: Benjamin Leavitt, 111 Garrison Avenue,
Jersey City; Perry O. Hall, 131 Kensington Avenue,
Jersey City.
Dr. G. N. J. Sommers, President of the State
Society, made a few remarks touching upon the
legislative activities of the State Society, concern-
ing which he stated that the bill providing for a
consolidation of all the State Boards would not be
passed. He also stressed the value of the Woman’s
Auxiliary, stating that the influence of a strong
auxiliary was valuable to the society and request-
ing the members to support it.
The speaker of the evening was Dr. John
Wyckoff and the subject “Digitalis”. Dr. Wyckoff
began by enumerating the many variable factors
in the giving of digitalis which affect the thera-
peutic results (1) The active principles may vary.
(2) The percent-ratio of the constituents vary. (3)
Absorbability of the principles varies. (4) Elimina-
tion of the principles varies. (5) Elimination-rate
of the different leaves varies. (6) The preparations
used vary. (7) The method of administration
varies, e.g.. mouth, rectal, subcutaneously and in-
travenously. (8) The various cardiac functions
affected by the drug vary in their response. The
drug acts differently in flutter, in fibrillation. Thus,
it is well seen that these numerous variables may
explain all the difficulties in the use of the drug
and the results obtained.
A brief history was then given of ihe discovery
of digitalis from the foxglove which Witlierington
found in the old lady’s formula, and the conclusions
of Witherington on the conditions, and amount of
the drug to be used; his 10 years’ observation,
published in pamphlet form, as well as the fact
that they were subsequently neglected by the pro-
fession, leading to misuse, abuse and disease.
In order to know the correct manner of using a
drug there are 4 factors which must be determined:
pharmocologic action to be expected; safe and ade-
quate dose; rate of absorption; rate of elimination.
Witherington thought that the action of digitalis
was mainly on the kidneys. Schneideberg, and
later Cushny, found its action to be on the heart.
There is much that we still do not know about the
drug but there are also a few things that we do
definitely know. We know that it (1) slows the
sinus rhythm; (2) acts on the auricular muscula-
ture and therefore can alter the circus movement
in the auricle: (3) acts on the A-V bundle and in-
hibits impulse passage, slowing conduction to the
ventiicle, and (4) acts on the ventricle, increasing
its contractile power.
Dr. Eggleston, in 1914, attempted to standardize
the dosage of digitalis necessary to produce thera-
peutic results, reporting on some 50 patients. He
attempted to correlate all available data, as to age,
sex, lesion, and bulk, but found that the only
near-constant ratio existed between the weight of
the edema-free patient and the amount of digitalis
used. This he fixed at 0.15 cat units, per pound
of body weight. His studies were corroborated by
both Robinson and Henry Christian.
A description of the attempts to study elimina-
tion of the drug, by Eggleston and Wyckoff, was
then given. Absorption of the drug was found to
begin 15 minutes after oral ingestion and to be
complete in 6-8 hours. Pardee’s experiments on
elimination were cited, in which it was found that
the fully digitalized patient eliminated about 20
minims of the tincture per day.
Dr. Wyckoff then showed a large number of
lantern slides graphically depicting use of digitalis
in the various cardiopathies. He stressed the im-
portance of not conflicting the periods of digitaliza-
tion and maintenance.
1 he safest way to give digitalis is rapidly, with
diminishing fractional doses. Most patients need
about 20 gr. to produce the desired results. Main-
tenance can be determined only by the thera-
peutic test, which is a sufficient amount to main-
tain a ventricular rate of 72-90 with the patient at
rest for 10 minutes.
I he best preparation to use is capsules of the
powdered leaf, but this is quite expensive. Tab-
lets aie the next best, and tincture the poorest.
The belief that digitalis preparations deteriorate
rapidly is erroneous, but preparations must be
standardized, for most of them vary greatly from
required strengths.
The best way to take the drug is by mouth. If
not tolerated, it is then best given by rectum, as
suppositories, 3 gr. being a maintenance dose. To
gi\e the drug intravenously is seldom necessary.
Given so, ouabain is best, 0.1 mgm. dose, up to
10 doses.
Ba > on lie Hospital Clinical Conference
Maurice Shapiro, M.D., Secretary
The regular meeting of the Clinical Conference
of Bayonne Hospital Staff was held Monday even-
ing, January ;>, tinder the presidency of Dr.
Donohoe.
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
181
Dr. Sklar reported cases from Medical Service
of Dr. Deary.
Case 1. J. G., aged 46, male, was admitted De-
cember 5 with the chief complaints of cough, loss
of weight, hoarseness and night sweats. Patient, a
sand blaster, gave the history of a cough, pro-
ductive of a thin, watery hemorrhagic sputum for
the past 8 months, associated with loss of 20 lb.
weight, extreme weakness and night sweats.
Lung percussion resonance was slightly di-
minished throughout both lungs. Breath sounds
were also proportionately diminished in intensity,
especially at the bases; sibilant rales were heard
at both bases, but no moist post-tussive rdles
could be elicited. On percussion, the heart sounds
were regular, rhythmic and of good quality. The
rate was normal. Pressure 124/70. Blood picture
normal except for very slight secondary anemia.
Sputum negative for tubercule bacillus.
Radiography showed generalized, parenchymatous
infiltration of both lungs. In the hilus a fairly
large sized area of calcification, probably due to an
old calcified gland. Tracheal shadow deviated to
the right. Between the upper and middle lobes,
right side, evidence of an old interlobar pleurisy.
This was diagnosed as a case of pneumoconiosis,
silicosis variety, due to steel and iron dust. With
rest in bed and the usual expectorants improved
slightly and was allowed to go home.
Case 2. E. S., male, aged 20 years, white, was ad-
mitted November 24 with chief complaint of swell-
ing of right ankle. History of a gradual painful
swelling over a period of 4 weeks, becoming so bad
that he was forced to bed. No other joints in-
volved. No history of trauma or rheumatic fever.
Denied gonorrheal infection.
- Examination revealed no positive finding besides
several carious teeth and a swollen, reddened
right ankle joint that was very painful on motion
and tender to touch.
Urine negative except for faint traces of albumin.
Blood count, slight secondary anemia; W. B. C.
12,000; 80% polys. Wassermann negative. Pros-
tatic smear showed many intracellular liplococci.
X-ray examination of foot indicated the presence
of an osteo-arthritis of the fourth metatarso-
phalangeal articulation.
Upon a diagnosis of gonorrheal arthritis, the foot
■ was immobilized and vaccine injections were in-
stituted. In 24 hours after first injection he de-
veloped an acute congestive conjunctivitis, from
which we found some Gram-positive diplococci and
a few Gram -negative bacilli. This conjunctivitis
was at first thought to be a specific reaction to
vaccine, but on later observation patient was found
to have an infective origin.
The foot responded slowly but surely to treat-
ment so that presently he was up and about the
ward. The conjunctivitis also responded well to
cold compresses, argyrol and atropin.
Case 3. J. C., male, white, aged 43, fireman in
chemical works, was admitted complaining of
weakness and increasing pallor. For 2 months he
had noticed a progressive paling of his skin as-
sociated with weakness, pain in chest, some cough
and dark expectoration. No hemoptysis, numb-
ness or tingling in hands or feet. He also noticed
that he was dyspneic upon mild exertion and that
his ankles had become swollen 2 weeks before ad-
mission. Lungs negative except for occasional
rales at both bases. Slightly enlarged heart ; regu-
lar sound of good quality; hemic murmur, systolic
in time at apex.
Blood picture was that of a severe secondary
anemia. Wassermann and Kahn tests negative.
Consultation with genito-urinary department re-
vealed the following; Left kidney diminished func-
tion; right kidney no function. Pyelogram showed
congenital kidney anomaly, probably a horse-shoe
kidney and a right hydropyonephrosis. The pelves
were drained several times, with some sympto-
matic and subjective relief, but his anemia im-
proved very slightly. Impression, severe secondary
anemia on basis of urologic lesion mentioned.
Dr. Madras reported from the Surgical Service
of Dr. Donohoe.
Case 1. S. J., aged 44, admitted with a history of
acute abdominal pain of 20 hr. duration, following
ingestion of heavy meals during the Christmas
holidays. For about 3 years complained of occa-
sional epigastric distress, with belching of gas and
sour eructations, and chronic constipation. There
was no nausea or vomiting. Had never consulted a
doctor for this condition. On admission, in shock;
pulse 140; temp. 104°; nausea and vomiting. Gen-
eralized tenderness, most marked in epigastrium
with marked distention.
Perforated gastric or duodenal ulcer was diag-
nosed and immediate laparotomy advised.
Abdomen was filled with a tremendous quantity
of fluid, together with a mass of undigested food.
This was sucked out as rapidly as possible, the
fluid being deeper in color near the pyloric region,
where the structures were bound down, and be-
cause of mordant condition further exploration was
inadvisable. Drains were inserted and abdomen
closed rapidly with through and through silk worm
sutures. Patient was given stimulants, hypoder-
moclysis of 1000 c.c. warm glucose and saline, but
he expired 10 hours after operation.
Case 2. J. M., aged 13 years, male, admitted be-
cause of pain in lower abdomen ; onset 1 day pre-
viously, pain being centered around umbilicus and
accompanied by nausea and vomiting. Vomiting
continued and pain finally became localized in
right lower quadrant. Diagnosis of appendicitis was
made and immediate operation advised.
The appendix was markedly swollen in distal
third; vessels congested; serosa covered with
fibrin; and the tip, adherent to the mesentery,
was packed with fecal material. Postoperative
course was turbulent, and on sixth day wound
was inspected and probed in lower angle, and about
100 c.c. of pus evacuated. On seventh day occa-
sional vomiting, wound broken down, draining, but
no relief from ileus. An opening was made into
abdomen with a Kelly clamp and 5 oz. of an opa-
que, yellow fluid was removed; culture from which
showed Gram-positive cocci and Staphylococcus
aureus. On ninth day patient vomited fecal mat-
ter and distention showed no signs of decreasing;
temperature 103°, pulse 140. The old incision was
lengthened and the rectus retracted medially. The
cecum was found distended and there was a partial
volvulus caused by adhesion of a loop of small in-
testine to the lower portion of the cecum. The
child’s condition became desperate — almost pulse-
less— so the adhesions were separated and a rapid
cecostomy performed. Stimulants were given and
saline intravenously. Following day there was a re-
markable change for the better, and the wound
was draining large amount of fecal matter. Abund-
182
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
ance of fluids was forced by mouth. Six days fol-
lowing: the lube was removed but cecum was drain-
ing- profusely. Seventeen days following operation
patient had a bowel movement but the fistula
drained profusely. Wound began to heal, fistula
becoming smaller and gradually closed. Child was
extremely emaciated — appetite became voracious.
Discharged 2 months after admission, and his con-
dition has remained excellent.
Dr. Antopol reported upon a patient, male, aged
45 years, admitted to the hospital with a chronic
cough of 2 years’ duration, and loss of considerable
weight. Two weeks before admission had coughed
up a copious amount of foul smelling sputum and
complained of pain in the right chest. On admis-
sion a right thoracentesis was performed and the
chest found to contain a considerable amount of
purulent material, which on smear and culture
showed Gram-positive diplococci and streptococci.
The material coughed up by the patient contained
the same organisms and was similar in nature to
that of the chest fluid. The patient died 4 days
after admission, and autopsy disclosed a massive
purulent effusion, 1000 c.c., in the right chest;
pleura markedly thickened; in the right lower lobe
main bronchus a marked infiltration of the entire
wall causing a bronchostenosis at this point; di-
lation of all the bronchi of the right lower lobe,
with purulent material similar to that found in the
pleura. On microscopic examination the diagnosis
of metaplastic bronchus carcinoma of the right
lower lobe, with extention into the peribronchial
areas and metastases to the tracheobronchial
lymph-nodes was confirmed. The cells appeared
to be of the squamous variety, in places showing a
tendency to pearl formation. The origin was
thought to be from metaplastic columnar epi-
thelium of the bronchus lining.
Clinical Society of North Hudson Hospital
J. Africano, M.D., Reporter
The regular monthly meeting of the Clinical So-
ciety was held Tuesday, January 13, with Dr. Louis
C. Lange acting as chairman; 44 members and
guests were present.
Dr. Tanncrt read the hopsital report for De-
cember: 250 admissions and 284 discharges; 21
deaths, of which 12 were medical, 3 surgical, 2
pediatric, 2 gynecologic, 1 urologic and 1 new-
born: 7 autopsies were performed, or 33% of all
deaths; clinic cases 415, emergency cases 419, am-
bulance calls 93; there was a tremendous amount
of work done by the laboratory — 1989 miscel-
laneous examinations.
Dr. IT. Braunstein discussed 6 of the autopsies,
the report of the seventh being withheld pending
a court trial. One death resulted from peritonitis
and septicemia following self-induced abortion: a
patient who had successfully induced 9 abortions
but following the tenth developed trouble.
Dr. M. Green : Unusual Case of Bronchopneu-
monia. It. S., male, aged 31, colored, admitted De-
cember 1 complaining of cough, frontal headache
and hemoptysis. Past history : frequent sore
throats during childhood; diphtheria at 13; chancre
(?) at 17; pneumonia 1 yr. ago and confined in
the Jersey City Hospital for 3 weeks, since when
he has noticed a steady loss in weight amounting
to about 30 lb.
Three days before admission he had a severe chill ,
became very weak, with marked vertigo, and had
to go to bed; developed severe cough and frontal
headache, and coughed up some bright red blood.
Bronchovesicular breath sounds and increased
vocal fremitus heard anteriorly over both sides
of chest; dulness and amphoric type of breath-
ing found over the left lower lobe; friction rub
heard below angle of the left scapula; fine, moist
rales audible over both apices, while coarse
rales could be heard at both bases. Heart sounds
of poor quality. Abdomen slightly distended.
Blood pressure 118/68; temp., 106°; pulse, 112;
resp., 40.
The outstanding features during his 4 days in
the hospital were the profound toxemia and de-
lirium, with aggravation of symptoms; temperature
ran as high as 106°; icteric tint of the sclera; pneu-
monia signs spread over wider area in both lungs;
because of the mental state, no oral medication or
nourishment cOidd be given.
The clinical diagnosis was pulmonary tuber-
culosis with a terminal bronchopneumonia. Au-
topsy disclosed moderate amount of clear peri-
cardial fluid; no free fluid in the pleural cavities;
left lung adherent to the parietal wall and dia-
phragm, and showed beginning gangrene at the
base; right lower lobe consolidated.
The chronic cough, loss in weight, hemoptysis,
anorexia and color of the patient certainly war-
ranted diagnosis of pulmonary tuberculosis, but no
evidence of such lesion could be found at autopsy,
The other interesting feature in this case was the
over- whelming toxemia which persisted for 4
days.
Dr. Terk : Recurrent Lobar Pneumonia. S. lb,
male, aged 24, pipe fitter, admitted with history of
an occasional non-productive cough and 3 previous
attacks of right -sided pneumonia.
From the anterior axillary line going posteriorly,
including axillary area to about midway in the
right interscapular region, there was a definite dul-
ness, bronchovesicular breathing, increased vocal
and tactile fremitus, with scattered crepitant
rales.
Roentgenogram showed: “Obliteration of the en-
tire right chest. No fluid level. Left chest and
heart normal.” Examination indicated effusion in
the lower right chest. An attempt to aspirate was
made, but we obtained only a few drops of frothy
blood, and the needle was immediately withdrawn;
patient then began coughing up considerable blood.
Blood pressure 410/60;. temperature rose to 102°,
and pulse to 100. Condition remained about the
same for 1 week and then showed improvement.
At end of 3 weeks radiograph showed islands of
infiltration reported as sequels of pneumonia. Ex-
amination at this time showed the lungs clear ex-
cept for slight impairment of breath sounds and a
few crepitant rales in the lower right base. Dis-
charged 4 days later as cured.
Dr. Justin said that although aspiration was
negative, fluid was undoubtedly present as shown
by the physical signs and x-ray plates; the needle
punctured the lung and the patient promptly
coughed up some blood; the fluid was absorbed
rapidly and completely: reappearance of fluid made
it suspicious of a tuberculous origin, though
sputum examinations were consistently negative.
Dr. Pearlstein emphasized that pneumonia pro-
duces no immunity, but on the contrary, increas-
ing susceptibility; some patients are peculiarly
susceptible to the pneumococcus.
Eeb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
183
Dr Arthur Justin Bronchopneumonia a, Post-
operative Complication. J. R., male, aged 56, mar-
ried, laborer; admitted with past history negative
except for excessive alcohol consumption, and
present history of cough tor 2 years, productive of
yellow phlegm, recently lessened since be re-
duced his smoking. Illness began with dull pain 1
in. below the umbilicus and shifted to the right
abdomen. This distress continued, with pain worse
in hr. after eating, and on deep breathing. Tem-
perature, 102°; pulse 90; resp., 20. B. P. 170/84.
Systolic murmur at apex. Coarse moist rales over
entire anterior chest and posteriorly over the
apices and interscapular regions. Abdomen showed,
moderate rigidity over the right side from costal
margin to iliac crest. Tenderness 2 in. below right
costal margin.
Blood count: YY. B. C., 8200: polys., 80%; Hb.,
80% ; R.B.C., 5,000,000. Tentative diagnosis: Acute
appendicitis; acute cholecystitis; pulmonary tuber-
culosis. On the day following admission, he was
operated upon under ether anesthesia, with find-
ings of a thickened gall-bladder, many adhesions,
no stones, appendix twisted and fibrotic with many
adhesions.
His first week was a stormy one; developed
severe delirium tremens and reefuired restraint.
Surgical progress was reported as satisfactory, but
we noted an acutely ill man, moderately delirious',
dyspneic, cyanotic and presenting signs of bron-
chopneumonia with areas of consolidation in the
left upper, left lower, and right lower lobes.
Sputum showed pneumococcus Type IV: negative
for tubercle bacillus.
After 4 days, improvement began and radio-
graph indicated generalized tuberculosis of both
lungs. A left pleural to-and-fro rub was felt and
heard; 1 oz. blood tinged, turbid, yellowish fluid
was removed from the base of the left chest, and
smear showed round cells with very few polys.
During this period of 1 month there wife a di-
minished expansion of the left chest, dulness in
the left axilla, both bases showed harsh breath
sounds, rales above and below both clavicles an-
teriorly and posteriorly and over both lower lobes.
Repeated radiographs showed the same original
findings although the bronchopneumonia areas
were greatly diminished in size. The patient was
seen by Dr. Spalding, who reported bronchopneu-
monia and chronic fibroid phthisis.
The case is presented to emphasize the im-
portance of a. careful examination of the chest of
all patients who are to •have an ether anesthesia;
and the prolonged duration of findings which must
lie regarded as chronic bronchopneumonia, in the
absence of finding tubercle bacilli, although clini-
cally the history would indicate an activation of
tuberculosis of the lungs.
Dr. Lange. Empyema a Postoperative Complica-
tion. N. »M., male, aged 38, admitted with history
of having been shot in the abdomen 1 hour pre-
viously.
Immediately brought, to the. operating room
where 8 perforations of the jejunum and 4 of the
mesentery were closed. He reacted fairly well
from operation and was doing well until the fourth
day postoperative, when he had a chill and tem-
perature rose to 102.2°. Tissue about the wound
of exit, about % in., was gangrenous and emphy-
sematous on palpation. Diagnosis of gas-bacillus
infection was made and he was given gas-gangrene
polyvalent antitoxin on 3 days following. On the
fourth day postoperative, examination of the chest
showed tubular to bronchial breathing in the
lateral aspect of right lower lobe, as well as pos-
teriorly. Slight impaired resonance on percussion
over same area. Radiograph on seventh day post-
operative revealed a pneumonic, process in the
right lower lobe. Physical signs remained the same
until tenth day, when flatness on percussion was
elicited in the right lower chest, with distant to
absent breath sounds. A diagnosis of fluid in the
right chest was made. Thoracentesis was done at
this time and 8 oz. blood-tinged serous fluid was
withdrawn — there was no evidence of any purulent
material.
The physical signs in the right chest have re-
mained the same up to the present time — no change
after repeated thoracenteses.
Dr. Sell wfflnzwalil : Empyema a Postoperative
Complication. G. YY., female, aged 17, admitted
with chief complaint of pain in light lower quad-
rant of abdomen. Two years ago, patient suddenly
had a severe pain in, the right lower quadrant,
which was intermittent, dull and cramplike in
character. .Pain lasted 1 day and then disappeared.
In May 1930 she had a severe attack, and was
told she had appendicitis. Examination negative
except for some tenderness in right lower quad-
rant, about 1 in. medial and 1 in. above the an-
terior superior spine; also some tenderness to
right of the umbilicus. No rebound tenderness, no
rigidity, no masses palpable. A few rales, heard
anteriorly, disappeared on coughing.
Appendectomy was performed December 5. The
findings were a mobile dilated cecum, about 1 oz.
serous fluid in the abdomen and a subacutely in-
flamed appendix. The first day postoperative, tem-
perature rose to 102", pulse 110, respirations 26
and patient was coughing and expectorating mucus
streaked with bright red blood. The second day
she complained of slight pain in the chest, and
examination showed bronchial breathing at the
left base. Diagnosis: Postoperative pneumonia.
She developed an extensive pleural exudate, and
it was decided to tap the chest to determine na-
ture of the fluid. Thoracentesis was done and
about 16 oz. of a pea-green purulent fluid was re-
moved from the left chest.
X-ray picture taken the next day showed heart
pushed to right; obliteration of lower left lobe
with pneumothorax upper left; collapsed lung with
fluid level; hydropneumothorax.
Because this was a streptococcus empyema, it
was decided to wait several days before operating.
Rib resection was performed, releasing about 2 %
quarts of a bright, yellowush-green, purulent ma-
terial. containing thick, coagulated, fibrinous clots.
The pleura and the pericardium were covered by a
thick, coagulated fibrinous material. Closed method
of drainage was employed by suturing the opera-
tive wound tight about the tube, and tubes attached
for irrigation with Dakin’s solution. Postopera-
tive course uneventful. Discharge rapidly cleared.
Radiograph now shows the left chest to be clear
except for a slight amount of fluid at the costo-
phrenic angle. The left lung is expanding.
Dr. Roberts: Case of Postoperative Pulmonary
Embolism. A well-developed and well-nourished
woman of 36 suffering from fibroid tumor of the
uterus. Uneventful convalescense after hysterect-
omy except that she had a, slight rise in tempera-
ture on the eighth day, which, apparently was due
to a dry pleurisy. There was no suspicion of a
lung infarct. Heat, strapping and the administra-
tion of 10 gr. acetysalicylic acid relieved the dis-
184
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
comfort. Suddenly, on the night of the tenth day
postoperative, the patient was seized with severe
pain in the chest, was markedly dyspneic and
cyanotic, and died in about 2 minutes despite all
remedial measures.
I thought it might be of interest to scan the
records of the hospital for similar cases in the
past 2 years. In that time we have had 6 deaths
from postoperative pulmonary embolism, ranging
in time from 2 to 42 days. Two followed hyster-
ectomies, while the remaining 4 followed extensive
abdominal work, such as colostomy, release of post-
operative adhesions, jejunostomy, and drainage of an
extensive peritonitis. The age incidence was 38 to
63. In all cases there was no warning whatso-
ever; 3 patients had been up and about for several
days, while the other 3 were still confined to bed.
HUNTERDON COUNTY
Barclay S. Fuhrmann, M.D.. Reporter
The regular quarterly meeting of the Hunterdon
County Medical Society was held at Frenchtown,
January 20, at 11 a. m. Present: Drs. Gramsch,
Slavin, Decker, Closson, M. H. Harmon, B. M.
Harmon, Salmon, McCorkle, Tompkins, Sommer
and Fuhrmann.
The meeting was called to order by Dr. W. E.
McCorkle, Second Vice-President. After reading
the minutes, which were approved as corrected,
and correspondence which was ordered filed, the
censors having approved the application of Dr. F.
O. Slavin he was unanimously elected to member-
ship.
The subject of Councillor District Meetings was
presented by the secretary, quoting from the re-
port of The Conference of Secretaries and Report-
ers as found in the December Journal, and after
some discussion it was decided that the subject
be held in abeyance for further consideration at a
future meeting.
The program for the April meeting in Fleming-
ton is to be devoted to the subject of "Potter’s
Version”, and Dr. E. F. Purcell is to be invited
to be present and show his pictures on that sub-
ject.
Dr. McCorkle extended greetings to our new
member, Dr. Slavin, after which the meeting ad-
journed, dinner was served, and then our usual
round-table discussion ensued.
MERCER COUNTY
A. Dunbar Hutchinson. M.D., Secretary
The Mercer County Medical Society met in the
Carteret Club, January 14, Vice-President William
L. Wilbur presiding in the absence of President
Swern who was ill. The minutes of the preceding
meeting were read and approved.
Dr. John A. Kolmer delivered a very interesting
address on "The Nature of Bacteriophage and Its
Practical Application in Treatment". Dr. Kolmer
reviewed the early study of agar plate cultures in
1918, with a synopsis of results obtained by Dr.
Durrell and others. The culture, development, re-
actions and manner of application, with resulting
effects upon involved tissues, were most entertain-
ingly and instructively defined.
Dr. Kolmer very kindly answered many ques-
tions propounded during the interesting discussion
which followed.
Dr. L. Samuel Sica presented a copy of recom-
mendations drawn by the Committee on the Bureau
of Compensation, as follows:
' “It is suggested by the Mercer County Com-
ponent Medical Society that in formal hearings
held by the Compensation Bureau a physician
should be designated by the Commissioner of
Labor, who shall receive a salary from the De-
partment of Labor, and shall recommend to the
referee holding such informal hearings (upon re-
quest of such referee) the extent of temporary
and permanent disability of persons applying to
the bureau for compensation; to be made after
proper examination. This physician shall not, in
any compensation case, whether heard informally
or formally, before a referee or deputy commis-
sioner, give testimony on behalf of either the pe-
titioner or respondent, but such physician may,
under regulation of the Commissioner of Labor,
give testimony at formal hearings in cases where
he has previously examined the petitioner on be-
half of the state, with the restriction that he
shall not be employed by either the petitioner or
the respondent to give expert testimony in their
behalf, but such testimony shall be given only to
assist the referee or deputy commissioner in ar-
riving at a decision.
Such physician shall not, while he is employed
by the Department of Labor in such capacity, be in
the employ of any insurance carrier or self-insurer
handling compensation cases.”
Dr. Peter J. Warter was elected an active mem-
ber. Drs. Harry R. Aronis, Herman Cohen, Mor-
ton Reese-Cohen, and Thomas V. Murto were elect-
ed associate members.
MIDDLESEX COUNTY
S. G. Berkow, M.D., Reporter
Regular meeting of the Middlesex County Medi-
cal Society was held January 21 at the Perth Am-
boy City Hospital, Dr. Wm. J. McCormick pre-
siding. Attendance, 27.
The regular order of business was dispensed
with to enable Prof. Bryans, of Rutgers University,
to address the members on post-graduate courses
offered this year by the State Medical Society in co-
operation with the University. Suggestions by sev-
eral of the members were noted by the speaker for
consideration by his committee.
The scheduled address was given by Dr. H. H.
Ritter, Associate Professor of Traumatic Surgery,
Post-Graduate Hospital, New Yrork, on “Some In-
teresting Phases of Traumatic Surgery". The
speaker gave a practical outline of the treatment
of burns and other wounds and showed pictures of
the blanket treatment of separation of the symphy-
sis pubis. He then exhibited lantern slides of 2
rare cases, one an anterior dislocation at the knee
joint, and the other a midtarsal dislocation.
Active discussion attested the interest of the
members.
At the suggestion of the Chair, a short discussion
was held on the advisability of changing the meet-
ing time from afternoon to evening. Without form-
al motion and vote, the members declared in favor
of holding the next meeting at 9 p. m.
Feb., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
185
Medical Section Rutgers Club
J. H. Rowland, M.D., Secretary
The regular monthly meeting of the Medical
Section of the Rutgers Club was held at the Elks’
Club. New Brunswick, on Friday evening, January
16, Dr. William Klein presiding. There were 35
members, friends and guests present.
There being no business to transact, the speaker
of the evening was immediately introduced. Dr.
Myron Sulzberger, Associate Professor of the Post-
Graduate Hospital, New York, gave a very in-
structive talk on “The Association of Industry and
Skin Diseases”. His talk was very complete, and
considered principally the frequency and the eco-
nomic aspect of industrial skin diseases. He stressed
the importance of differential diagnosis, especially
where it concerned compensation ; emphasized the
importance of diagnosis, establishment of cause
by means of the patch testing method, and treat-
ment. which concerned principally removal of
cause, if possible, desensitization, and symptomatic
treatment. Lecture was illustrated by lantern
slides.
Following the lecture, members adjourned to the
dining room where entertainment was provided
by the hosts of the evening, Drs. Hoffman, Howley,
Johnson and Karshmer.
MORRIS COUNTY
Marcus A. Curry, M.D., Reporter
A special meeting of the Morris County Medical
Society was held the evening of January 22 at the
New Jersey State Hospital at Greystone Park.
Vice-President Krauss, in the absence of Presi-
dent Sutphen, who is convalescing from a severe
cold, presided over an attendance of approximately
60 members and guests.
Routine business included the reading by Secre-
tary Ward of minutes of the special meeting of
December 18. 1930, and the proceedings of a meet-
ing of the Executive Committee; the latter em-
bracing plans under wav for a Post-Graduate
Course of Lectures. Dr. Frost, of the committee
that is working out the plan with Rutgers Uni-
versity, reported the tentative arrangements for
the courses; indicating that they will be given at
Morristown Memorial and All Souls’, in Morris-
town, and the Dover General : and stating that
within a few days each member will receive a let-
ter outlining the plan.
Vice-President Krauss announced that Dr. Ross,
of New York, will speak on “State Medicine” at
the Academv of Medicine in Newark at 8:45 the
evening of February 12; this being a meeting of
the First Councillor District of the state.
Two new members were unanimously elected:
Drs. George Mitchell, of Hackettstown, and J. H.
Harrington, of Rockaway.
The scientific chapter of the evening was given
over to very interesting moving pictures, the films
for which were obtained from the Eastman Kodak
Company: the subjects covered being “Infections
of the Hand”, “Normal Brech Presentation” and
“Tests of Vestibular Function”. The pictures were
well and clearly projected, attentively witnessed
and proved to be very interesting.
The evening was rounded out with a social ses-
sion during which, at the invitation of Medical
Superintendent Doctor Curry, refreshments were
enjoyed.
PASSAIC COUNTY
W. W. Hall, M.D., Reporter
The regular meeting of the Passaic County Medi-
cal Society was held at the Valley View Sana-
torium, Paterson, on January 8, at 9 p. m., with
78 members present.
'Dr. Wm. P. Healy, attending Gynecologist to
the Memorial Hospital, New York, presented a
most interesting paper on “Pelvic Neoplasms, with
Special Reference to Carcinoma”.
Two applications for membership were presented
to the Board of Censors: Drs. Fritz Plinke, 99
Gregory Avenue, Passaic; and Nicholas Palma, 281
Broadway, Paterson.
A collation was served by the institution.
UNION COUNTY
Russell A. Shirrefs, M.D., Reporter
The regular quarterly meeting was held at the
Elizabeth General Hospital on the evening of
January 14, with Vice-President H. V. Hubbard
presiding. The essayist was Dr. Arthur R. Cassili.
of Elizabeth, who spoke on “The Third Circula-
tion (Cerebro-Spinal Fluid) and its Reflection of
the Central Nervous System Pathology”, illustrat-
ing his lecture with lantern slides. The discussion
was opened by Dr. Norton L. Wilson, who was
followed by Dr. Jack Blumberg and others.
New members elected were Drs. Herman H.
Goldstein, Walter H. Cole, Jr., Joseph E. Frank-
lin, George H. Friedburg, Joseph J. Butenas,
Joseph Sadoff, Albert G. Gorczyca, Russell G. Bir-
rell, all of Elizabeth; and Fred T. Hutton, of Plain-
field. Four proposals were also received for action
at the next meeting.
While the society was in session, its Woman’s
Auxiliary held a meeting at the Nurses' Home.
Mrs. H. V. Hubbard presided and Mrs. Charles A.
Hoffman, of Plainfield, was elected recording secre-
tary. Following the meeting both groups joined
and refreshments were served.
Summit Medical Society
W. J. Lamson, M.D., Reporter
The regular monthly meeting of the Summit
Medical Society was held at Wallace Pines on
Tuesday, January 27, with Dr. Prout entertaining,
and the President, Dr. Smalley, in the chair.
Present: 26 members and 8 guests.
The paper was read by Dr. Aaron S. Price, of
the Polyclinic Hospital, New York, on “The Clini-
cal Interpretation of Differential Blood Count”.
In appendicitis we look for an average leukocy-
tosis of 15,000 to 20,000. In general the more acute
the attack the higher the count will be.
In tuberculosis the polys are slightly diminished,
with a relative mononucleosis. An increase in the
polys shows a secondary infection.
In acute rheumatism the leukocyte count will
run to 16,000, and in order to avoid cardiac compli-
18G
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Feb., 1931
cations it is necessary to keep the patient flat on
his back in bed until the count reaches normal,
generally about G weeks.
In post-hemorrhagic anemia, and after splenec-
tomy, there is a transitory leukocytosis.
Eqsinophilia, as high as 20%, occurs in trichin-
iasis. It is an allergic reaction, and occurs also in
chronic bronchial asthma and in some skin dis-
eases.
Mononucleosis, 8 to 10%, in tuberculosis denotes
activity of the disease, but this is a favorable sign.
In typhoid there is a leukopenia with relative
mononucleosis. The toxin is destructive to leu-
kocytes.
In children with acute infections there is a
tendency to revert to the primitive kinds of
leukaeytes; thus, in pertussis, we find a large per-
centage of lymphocytes.
The paper was discussed by Drs. Thomson, Dis-
brow, Krauss, Prout and Johnston.
WARREN (OI'NTV
F. A. Shinier, M.D., Reporter
A regular quarterly meeting of the Warren
County Medical Society was held January 20 at
Farrell Arms Plaza, Washington, at 10.30 a. m.,
Dr. H. B. Bossard, the President, officiating. Mem-
bers present: Drs. H. B. Bossard, A. Zuck, F. Cur-
tis, G. H. Bloom, L. C. Osmun, C. B. Smith, G. W.
Cummins, G. O. Tunison, G. G. Mills and L. H.
Bloom. Drs. H. O. Reik and .1. B. Morrison, of the
State Medical Society, and Dr. Paul Correll, of
Easton, Pa., were in attendance as guests.
Dr. Correll read a very interesting paper on
' State Medicine”.
Dr. Morrison also read a paper on the present
medical conditions, and Dr. Reik discussed both
papers. Dr. Osmun spoke of the advantages of a
Post-Graduate Course offered by the State So-
ciety and urged the support of members.
There followed a general discussion in which
everbody took part. The meeting adjourned, and
dinner was served in the dining room of the Plaza.
Obituaries
SAVOYE, Richard G., of Westfield. Resolutions
adopted by the Union County Medical Society in
special session :
Whereas, Almighty God in His all-wise provi-
dence has chosen to remove from our midst our
fellow member, Richard G. Savoye, of Westfield,
New Jersey:
Therefore, be it resolved that in his death this
society, the community for which he lived, and the
profession at large have sustained a great loss.
Resolved, we express our appreciation of his in-
terest in Public Health work as President, for many
years, of the Board of Health of Westfield, as a
member of the Mosquito Commission of Union
County, and as a public spirited citizen.
Further, be it resolved that our sympathy be
extended to his bereaved family; that these reso-
lutions be spread in full on the minutes of this
society: and that a copy be sent to his. family.
.1. B. Harrison.
F. A. Kinch.
G. S. Laird.
MOORE, John H., of Bridgeton,, passed away
Jan. 2, 1931, at the age of 75 years. Born in 1S55,
son of a physician, Dr. Joseph Moore, he graduated
with honors at Princeton and then acquired his
medical degree at the University of Pennsylvania
in 1880. Throughout his long and successful career
as a physician and an active civic worker, Dr.
Moore found time to pursue steadily his study
of the classics. One could not know him an hour
without discovering that he was a ‘‘learned” man;
and yet withal he was modesty personified.
Outside the field of medical practice his greatest
service was rendered to the school affairs of
Bridgeton, and he served for 1!) years upon the
local Board of Education — continuing in that office
until he had attained his dream of a satisfactory
High School for that community.
The Meeting
By Anna Hamilton Wood
When Death and I come face to face at last,
1 do not think the burden of the past
Shall lean between us, but that I shall find
A gentle, valued friend, consoling, kind,
With depth of understanding so profound
That rituals and creeds shall be unwound
And, like frayed edges of a garment worn
Past usefulness or beauty, shall be torn
And thrown to discard. My nude soul shall stand.
Humble but shameless, and await command
For further service; years that went before
Locked out of sight forever by the door
Of silent Time, their only impress shown
By the degrees my spirit-life has grown.
How I shall smile to think that once I feared
This kindly comrade whose dread shape appeared
Cruelly distorted in his earthly guise —
For Death is God’s dear shadow to the wise!
The Cumberland County Medical Society, at a
special meeting called for the purpose, adopted
the following resolutions:
“The passing of Dr. John H. Moore has left, in
medical and social circles, a gap we cannot hope
to fill. A scholar and a gentleman of the old
school, Dr. Moore has exemplified for us the high
standards and excellencies of his generation. Per-
sonal dignity was his, unswerving loyalty to his
obligations and a fine sense of values, which led
him always to set the spiritual things of life,
above the gross and mercenary. Primarily he was
a man of intellect.
Those of us who were associated with him in
hospital and general medical work, as well as
those who shared his leisure hours, were alike im-
pressed by the brilliant mentality that enlivened
all he did. Fullness of years brought him a pro-
found philosophy of life, so that he met ill-health
and misadventure without bitterness, and con-
templated the inevitable with a calm fortitude.
In the feverish rush of crowded days, it behooves
us, his colleagues, to pause a moment for his
memory’s sake, and take heart and inspiration
from the honorableness of his wise and quiet
ways.”
187
Journal of The Medical Society of New Jersey
Published on
die First Day of Every Month
Vol. XXVIII., No. 3 ORANGE, N. J., MARCH, 1930
Subscription, $3.00 per Year
Single Copies. 30 Cents
DEVELOPMENT OF PUBLIC
WELFARE WORK*
Commissioner William J. Ellis
State Department of Institutions and Agencies
Trenton, N. J.
The law creating the State Board of Con-
trol of the Department of Institutions and
Agencies expressly enjoins that the state wel-
fare activities “shall be humanely, scientifi-
cally, efficiently and economically maintained
and operated’’. As a major policy, in pursu-
ance of this requirement of law, the State
Board of Control has recognized the funda-
mental importance of emphasizing the ad-
vantages of a program of intensive treatment,
training and rehabilitation instead of mere
custody of the wards of the state. To the
medical profession of the state and to the al-
lied professional workers in the laboratories,
in the nursing and educational profession, the
welfare institutions of New Jersey have
turned with confidence for the purpose of
carrying out these general policies.
Great progress has been made in the past
12-15 years in transforming public institu-
tions from places for custody only into treat-
ment hospitals and community centers for
physical, mental and social rehabilitation. The
legislature and successive governors have sup-
ported this program of treatment and rehabili-
tation because they, were convinced that the
advantages, both in terms of happiness and
*(Read at the 164th Annual Meeting of the
Medical Society of New Jersey, Atlantic City,
June 13, 1930.)
human welfare, as well as in terms of dollars
and cents, are outstanding.
In hospital and other treatment institu-
tions of the state and counties under this pro-
gram of treatment and rehabilitation, keepers
and guards have largely been replaced by
nurses, teachers, and occupational and physi-
cal therapy workers. The medical staffs have
been enlarged. They have also been supple-
mented by the addition of resident dentists,
pathologists, laboratory and x-ray technicians.
It is an out-worn view of public institutions
that they are places in which unfortunate in-
dividuals with mental or physical illnesses
should be locked up, simply to protect the
rest of society from infection or annoyance.
Modern institutions, such as the state and
county institutions in New Jersey, are most
important factors in the care, training and
rehabilitation of mentally and physically dis-
ordered persons. They play an important
role in the prevention and control of the dis-
eases afflicting these persons. In addition,
they are or can become very important hu-
man laboratories. New Jersey has taken a
leading place in the work of modernizing and
equipping state and county institutions to pro-
vide scientific care and assisting these insti-
tutions in serving as centers for disease pre-
vention activities.
Work in the Field of Tuberculosis
Great progress has been made during the
last 25 years in reduction of the tuberculosis
mortality rate in New Jersey, as elsewhere,
due to the joint efforts of many cooperating
forces. The remarkable decline in the num-
ber of cases throughout the state has been an
188
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
important contributing factor in prevention
of the spread of tuberculosis. This decline is
indicated by a drop in the mortality rate from
179.5 per 100,000 of the population, in 1904,
to 74.9 per 100,000 of the population in
1929; a decline of 58%. Many patients are
now seeking hospitalization in the early, cur-
able stages of that disease, when they will re-
spond to treatment. Thus the chances are in-
creased, that they may be discharged from a
sanatorium without danger to the community.
Improved state and county hospital facilities
and the application of modern medical meth-
ods have been instrumental in reducing the
number of cases of tuberculosis in the state.
I hrough the Extension Department of the
New Jersey State Sanatorium at Glen Gardner
more than 50 regular clinics are held ever)'
month in various parts of the state for ex-
amination and consultation, and approxi-
mately 7500 patients annually are thus ad-
vised by competent tuberculosis specialists.
The work of the County Sanatorium clinics
in Hudson, Bergen, Passaic, Union, Camden
Counties and elsewhere is outstanding in this
connection. The specialists serving these
clinics report that the majority of patients are
referred to them by practicing physicians, and
the clinics are working in thorough accord and
cooperation with the medical profession. These
clinics serve a most important function in
making competent, specialized diagnostic
facilities available to the people of the state,
even in remote rural communities. The re-
search activities of the Department and of
the Glen Gardner Sanatorium play an import-
ant part in pointing out the nature and extent
of the tuberculosis problem. A survey re-
cently completed by the Research Division in-
dicates that despite progress made in this
field there is still great need for intensive,
curative, as well as preventive work. The re-
cently published study revealed that 42% of
the 2500 patients entering New Jersey sana-
toriums for the first time in 1929 were be-
tween the ages of 15 and 29. This study
further showed that there is special need for
increased activity on the part of clinics and
the sanatoriums for the negroes; as 20% of
the cases of tuberculosis in New Jersey occur
among negroes, who make up only 4% of the
state’s population. This recent study also re-
vealed that patients are not remaining in sana-
toriums as long as is desirable; 15% of those
discharged remained less than 1 month; 27%
less than 2 months ; and 38% less than 3
months. Due to economic and social reasons,
many patients leave the sanatorium while they
are still a source of contagion to the com-
munity.
Further success in solving the problem of
tuberculosis in New Jersey can best be secured
by emphasizing to the public the necessity for
recognition of the early symptoms of tuber-
culosis and the prompt seeking of competent
medical care and direction.
Campaign Against Mental Disease
New Jersey, in common with other states,
has been waging an active campaign against
the apparent increase in mental disease. The
disturbing fact is that the rate of increase of
populations of hospitals for mental disease
here, as elsewhere throughout the country, is
exceeding the rate of increase of the general
population. Between 1910 and 1920 the gen-
eral population in New Jersey increased
24.4%, while the population of the mental
hospitals increased 36.4%. The Medical So-
ciety of New Jersey recognized the outstand-
ing importance of this problem when at its
meeting in 1929 it appointed a special com-
mittee, headed by Dr. Elmer Chase Jackson,
to cooperate with other agencies in dealing
with this problem. The State Board of Con-
trol, through its Committee on Mental Hy-
giene, of which Drs. Ambrose F. Dowd,
Augustus S. Knight, Joseph E. Raycroft and
George O’Hanlon, Mrs. H. Otto Wittpenn
and the writer are members, has cooperated
with Dr. Jackson and others in outlining a
program that is adapted to the needs of this
state. The Mental Hygiene Committee has
conferred with leading specialists in this and
other states and has outlined the following
major objectives as a means to check the
growth of mental disease and to discover ef-
fective preventive measures:
(1) We should continue our efforts to trans-
form existing mental hospitals into modern treat-
ment and curative institutions; this means the
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
189
provision of adequate treatment facilities' and a
trained medical staff with consultants to carry on
intensive treatment work, using the approved
methods of treatment applicable to these patients.
(2) There should be an increase in the psychia-
tric social service or follow-up field work, so as
to enable mental hospitals to parole early, under
proper conditions and safeguards, a greater num-
ber of patients who can be satisfactorily adjusted
in the community.
(3) There should be a continued extension of
the mental clinics based on the mental hospitals
to serve the communities in the diagnosis of men-
tal and nervous disorders, and to reach potential
sufferers from nervous or mental disorders.
(4) The local communities should be encouraged
to develop psychopathic departments for mental
and nervous patients as part of the local general
hospitals. Such a psychopathic department con-
nected with a general hospital would be valuable as
a “first aid station’’. It is suitable for the nervous
patient who feels the need of special care but is
unwilling to go to a public hospital for the insane.
Under these conditions the physicians and
psychiatrists can make their observations and
diagnoses and can outline treatment. This, in
many cases, will make it unnecessary for these
patients to seek admission to the state and
county mental hospitals. Medical specialists
in mental diseases, psychiatrists in the local
communities or from the state or county hos-
pitals, can be secured as consultants to these
psychopathic departments of the general hos-
pitals.
Mental patients should not be committed
to jails or lockups, as is now often done.
These persons are sick mentally and should
be sent to psychopathic departments of gener-
al hospitals, properly equipped to care for
such persons.
The Department has issued a publication
outlining some practical suggestions for the
development of psychiatric wards in connec-
tion with the wards of general hospitals.
Copies of this pamphlet were mailed to all
members of the State Medical Society and the
recommendations of this report have met with
the cordial approval of such outstanding lead-
ers in this field as Dr. Adolf Meyer, of Johns
Hopkins University ; Dr. Samuel Hamilton,
of the New York State Commission on Men-
tal Disease, and many others.
Those persons whose mental condition re-
quires hospitalization, and yet are not willing
to enter public institutions for the care of
mental diseases, can frequently be persuaded
to enter general hospitals equipped with
psychiatric wards. The success of psychiatric
wards in connection with the general hospitals
in Detroit, Albany, Jersey City and elsewhere
argues for the practicability and effectiveness
of this plan. General hospitals in most com-
munities already possess most of the facili-
ties necessary for treatment of nervous and
mental diseases, with relatively minor changes
in physical equipment and with the services
of practicing physicians and specialists in the
community, supplemented by consultation
service from state and county hospitals and
clinics.
Great progress can be made in bringing
about earlier recovery and in making com-
mitments to the county and state hospitals
unnecessary. The establishment of such
psychiatric departments in general hospitals
throughout the state is being urged by the
Department, and cooperation of the medical
profession and hospital boards is asked to
assure success of this plan.
Mental Hygiejme Clinics
Probably no phase of the state mental hy-
giene program is more important than that
dealing with mental hygiene clinics. The
major work of these clinics is to provide op-
portunities for early diagnosis of tendencies
and weaknesses that may, under strain, de-
velop into some form of mental weakness or
insanity, and to suggest treatment that will
counteract such tendencies. Twenty-five men-
tal hygiene clinics have been established in co-
operation with local medical authorities and
general hospitals. Cooperation of the medical
profession is particularly essential to their
success. If incipient nervous and mental dis-
orders can be detected in the early stages, many
social and economic disasters can be avoided.
That practicing physicians recognize the value
of these clinics for early diagnosis of mental
affections is indicated by the fact that during
the past year more than half of the patients
attending such clinics were referred by their
own physicians. The state does not aim to
duplicate any existing diagnostic services, but
rather to supplement the work of the general
hospitals and the local medical profession. In
no case have the clinics been established ex-
cept upon request of local authorities.
190
JOURNAL OF THE MEDICAL
SOCIETY OF NEW JERSEY
March, 1931
Mental Hospitals
Great progress has been made in the treat-
ment of mental diseases in state hospitals.
1 liese hospitals, which only a few years ago
were looked upon as asylums for the insane,
have been provided with modern equipment
for complete diagnostic services and for in-
tensive treatment of complicated physical and
mental conditions. The half-mill tax has
f
made possible, for example, provision of a
modern treatment and reception unit at Grey-
stone Park State Hospital, where well-equip-
ped departments are provided for the resi-
dent and visiting staffs of the institution to
carry forward their complete diagnostic and
treatment services. Similarly at the Trenton
State Hospital, with provision of modern
equipment such as is found in general hospitals,
the physical plant for correction of all types
of physical and mental defects has been pro-
vided. In addition to medical services render-
ed to patients, occupational therapy, physical
education and recreational activities of these
hospitals are under close supervision of the
Medical Department and are regulated in
accordance with the mental and physical needs
of the individual. The modern conception of
mental disease as something capable of im-
provement and cure in a large proportion of
cases under proper care and attention, has
resulted in preventing many patients from be-
coming custodial patients requiring a long term
of hospital residence. Many valuable research
studies into the causes, treatment and preven-
tion of mental disorders have been made at
the state institutions and the Department is
beginning to put into effect the results of their
findings.
The place of New Jersey, as a leader in the
field of mental disease treatment, has already
been established through work accomplished
by the Medical Director of the Trenton State
Hospital, Dr. Henry A. Cotton, and Dr. Mar-
cus A. Curry, Superintendent of Greystone
Park, and the well trained and experienced
resident staffs of these institutions.
Work for the Epileptics
The work of the State Institution for Epi-
leptics, at Skillman, which is recognized
throughout the country as one of the leading
institutions of its kind, is especially worthy
of mention. The gap left by the death of Dr.
David F. Weeks, for more than 20 years
Medical Director of the Skillman Village, has
been ably filled by his associate for more than
15 years, Dr. Daniel S. Renner, who has
built up during the past year a splendid staff
of competent medical men who are pursuing
careful investigations into the causes of epi-
lepsy and the most promising methods of
treatment.
The Training of Mental Defectives
In the field of mental deficiency New Jer-
sey has developed a plan of segregation and
intensive treatment looking toward self-sup-
port for those who are capable of being re-
turned to the community. The work of the
Vineland institutions is well known to all.
Through cooperation of the Research Depart-
ment of the Training School at Vineland the
State Board has outlined a program which
counts upon the full cooperation of medical
and educational authorities, social agencies,
and public health officials. Fundamental to
such a program is the provision for early
identification of all persons of degenerate
stock, with institutional care for those whose
degree of intelligence is so low that they can-
not care for themselves or provide decent sur-
roundings for their children. Industrial col-
onies and agricultural colonies for high grade
defectives are being developed so that men-
tally defective persons may find protection
and an opportunity to contribute largely to
their own support while under institutional
control and supervision. Further extension of
the training of backward and defective chil-
dren in the public schools is an essential and
important phase of this program of control
of the mentally deficient. It was through the
work of Goddard and Doll, at the Training
School at Vineland, that adaptation of the
Binet tests for the measurement of intelligence
of English speaking children was made pos-
sible. This laboratory is continuing to make im-
portant advances in the field of research. It
is our belief that the state could well afford
to concentrate upon additional efforts in this
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
191
direction. We have passed the period when
the public generally is satisfied! with mere
segregation as an adequate solution on the
part of the community to the growing prob-
lem in the field of mental deficiency, as in the
field of mental disease. New Jersey has been
a leader in developing methods of diagnosis,
institutional training and reeducation. It must
also develop, and, in every possible way, in-
crease the fund of knowledge as to causes of
mental disease and mental deficiency. In this
connection our chief reliance is upon the well
trained professional workers — psychiatrists,
psychologists and laboratory aides — -who can
point the way to better control of, these prob-
lems.
Crime and Delinquency
The field of crime and delinquency, which
has attracted special attention in the past year,
looks to the medical profession and to sociol-
ogists for basic data, so that promising efforts
can be made to prevent and control the appall-
ing increase in delinquency and crime. For
the past 12 years New Jersey has been apply-
ing in its correctional institutions methods of
diagnosis and treatment made available from
the fields of psychiatry and general medicine.
Thorough-going physical and mental examin-
ations have been made of all individuals com-
mitted to the penal and correctional institu-
tions. Recently, at the request of the National
Committee on Prisons and Prison Labor, a
complete survey of the findings of the indi-
vidual classification and study of the popula-
tion of the State Prison has been completed. In
this work the Department has had the assist-
ance of Hon. Joseph D. Sears, a member of
the Board of Managers of the State Prison, and
Dr. Edgar A. Doll, of the Research Depart-
ment of the Vineland Training School, a mem-
ber of the managing Board of the Rahway Re-
formatory, and the personnel of the Mental
Hygiene Clinic which senses the correctional
institutions. The study, based on the classifica-
tion of 2500 male prisoners, includes 2000
prisoners committed to the New Jersey State
Prison during the past 3 years, and 500 addi-
tional prisoners who were committed prior to
1927. ft will be of interest, I am sure, to those
of you who have been watching closely the
public discussion of crime and delinquency to
know that New Jersey, through a modern plan
of classification, has grouped its prisoners into
4 general classes, as follows :
(1) Difficult Class. This class is composed of
prisoners who are recidivists, who have antisocial
tendencies or who are diagnosed as psychopathies
and constitutional defectives, etc. This class makes
up a large percentage of the prison population and
requires, by and large, close custody and close
supervision.
(2) Better Class. This class is composed of
normal prisoners who are mentally and physically
able to be adjusted to society. For the purpose of
custody and training this class has been divided
into 3 groups:
(a) Normal prisoners who because of the type
of crime committed, or the length of sentence,
require close custody but are suitable for shop
work and will probably form the backbone of
the prison shop organization.
(b) Normal prisoners who are believed to be
stable and trustworthy and may be employed at
prison farms, road camps, etc., where only limit-
ed security and supervision are necessary.
(3) Feeble-Minded. Composed of border-line,
feeble-minded and simple feeble-minded, which in-
clude high and low grade morons and high im-
beciles.
(4) Infirm or Indigent. Composed of aged or
senile, chronically ill and the seriously crippled.
This group mq,y be segregated on farms of limited
security where they may be required to do no more
difficult work than their infirmities will allow.
Of the 2000 commitments to the State
Prison during the past 3 years, 35.5% have
been placed in Class 1, the so-called “Difficult
Class”.
The classification grouping of prisoners
designated as the more reformable, better type
of prisoners includes those normal prisoners
who are mentally and physically able and
likely to respond to processes of rehabilitation.
This group has been subdivided into those
normal prisoners who, because of crime com-
mitted or length of sentence, require close cus-
tody but who are suitable for assignment in
the Industrial Department and are capable of
industrial trades training with favorable out-
look for parole; 13.4% have been grouped in
this class. A subdivision of this same classi-
fication of normal prisoners who are believed
to be stable and trustworthy and who may be
usefully employed at prison farms, road camps
and land clearing enterprises, where only
limited supervision is necessary, included
37.5% of the 2000 prisoners studied. Group
3, the definitely feeble-minded, makes up
10.5% of the whole number of 2000 prison-
192
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
ers. Nearly 2 % (1.7) were classified as aged
or senile, chronically ill and seriously crippled,
requiring segregation on farms with limited
security. Of the total number of 2000 com-
mitments only 1.5% were diagnosed as defin-
itely psychotic and epileptic.
Institution for Defective Delinquents
an Urgent Need
In developing a state program for meeting
the penal and correctional problems, special
attention must necessarily be directed toward
the mentally deficient group, including also
the psychopathic and constitutional defectives,
who are not good risks for parole from the
penal and correctional institutions to the com-
munity. The classification studies of these
prisoners indicate the necessity for a special
type of institution for defective delinquents,
as developed at Napanoch, New York, and
Bridgewater, Massachusetts. It is unwise pub-
lic policy, and in every respect poor business,
to release this type of offender under parole
conditions without a long period of penal or
correctional institution care.
One of the outstanding needs in New Jer-
sey is the development of a specialized insti-
tution for defective delinquents, thus remov-
ing from the penal and correctional group the
type of prisoners with whom these institutions
are ill prepared to cope. They should be placed
under medical and custodial supervision, as
they are not likely to respond to processes of
social rehabilitation and at the end of a fixed
term in a penal institution must under exist-
ing laws be released only to repeat their
offenses. No more urgent problem faces those
responsible for penal and correctional affairs.
No adequate solution can be projected for the
problem of crime and delinquency without
stressing the need for specialized facilities for
segregation and long continued care of this
type of prisoner under conditions where he
may be usefully employed and where society
can be secured from repetition of his criminal
propensities.
Throughout the institution system the work
of the medical profession and other specialists
has been of the greatest helpfulness and sig-
nificance.
Summary and Conclusion
I would sum up the development of the out-
standing policies for the institutions of the
state as follows.
(1) We have emphasized the importance of
treatment, training, and wherever possible
social rehabilitation, instead of mere custody
of the wards of the state.
(2) The cooperative features of institu-
tions have been stressed particularly by em-
phasizing the unity of the institutions of the
state, providing for interchange of products
of institutional labor, for example, and appli-
cation of methods of treatment developed in
the hospital group, to the same types of indi-
viduals when found in the correctional group.
(3) Through its welfare divisions, we have
stressed the importance of prevention and of
using the institutions as social laboratories
where the lessons learned through treatment
of the abnormal may be brought to the public.
(4) There has been developed a plan for
informing the public along constructive lines
of the work of the local institutions -and
agencies.
In addition to the responsibilities for gen-
eral policy-making for the development of the
state institutions and agencies, the State Board
has responsibility for visitation and inspection
of all county and city jails, places of detention,
county and municipal work-houses, county
penitentiaries, county insane and tuberculosis
hospitals, poor farms, alms-houses, county
and municipal schools of detention, and of
privately maintained institutions and agencies
for the care and treatment of insane, blind,
deaf, dumb, epileptic, feeble-minded, or other
physically and mentally defective, and for the
care of dependent and convalescent children.
In its relations to local institutions, whether
public or semi-public, the Department has
sought to assist in building up local initiative
and promoting a sense of local responsibility.
It has aimed to promote a wider knowledge of
the methods of care, treatment and training
of the mentally and physically handicapped,
and has advised as to standards of manage-
ment, building, construction and medical care
for the wards of the state, counties and mu-
nicipalities. Through the Department there is
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
193
afforded an opportunity for leadership in
specialized service, utilizing not only the full
time employees of the Central Department,
but also making available the expert heads
of the several institutions of the state or the
members of the staffs of these institutions,
for the benefit of other institutions of the
state and its subdivisions.
In line with its general policies, the De-
partment and the institutions have developed
specialized clinics, based upon the large state
hospitals and staffed by experts from these
hospitals. These clinics, serving in the field
of mental hygiene and tuberculosis, have ex-
tended their services from the state institu-
tions without duplicating or interfering with
the services of the local hospitals. Underlying
policies in the development of clinic service
have been cooperation with local general hos-
pitals or special hospitals for mental diseases
or tuberculosis; limitation of service to diag-
nostic work or follow-up work of patients
who have been released from the state insti-
tutions ; and development of the full use of
local physicians and local hospital facilities.
These policies have won support and coopera-
tion in all centers where clinics have been es-
tablished, and have brought about a splendid
spirit of cooperation between state institutions
and local clinics and hospitals.
INFLUENCE OF PUBLIC HEALTH
ACTIVITIES ON MEDICAL
PRACTICE*
Julius Levy, M.D.,
Newark, N. J.
For the past 2 or 3 days we have been
hearing a great deal about the relation of the
profession to public health activities, and I
think you have had it dealt with in several
ways. One of the speakers was disposed to
give us a sense of security by ridiculing some
of the modern trends and tendencies. Another
was disposed to instil in us a considerable
*(Read at the 164th Annual Meeting of the Medi-
cal Society of New Jersey, Atlantic City, June 13,
1930.)
sense of fear in dealing with the subject. I
am prompted to try rather to help us under-
stand some of the motivations behind both the
public health activities and the medical profes-
sion. I think we can take a leaf from the
modern tendency in psycho-analysis and real-
ize that if once we succeed in understanding
why we do things, it is much easier to correct
our method of doing them, and so I ask you
to follow me in an attempt to explain in a
rather cursory way the trend of public health
and also the trend of medical practice.
It is perfectly obvious to all of us in this
discussion that public health activities have
removed from medical practice a considerable
amount of disease and sickness. It is also
obvious, I think, that public health has created
a great amount of practice, if we are dis-
posed to take advantage of the opportunity.
Public health can be divided practically into
3 phases: The first may be described as that
which deals with prevention of disease through
the control of environment. Public health de-
partments, learning through the research work
of epidemiologists that certain diseases could
be controlled and prevented by controlling
milk and water supplies, established elaborate
systems for inspection and control of those
essentials in living, which have practically
eliminated milk-and-water-borne diseases ;
for instance, typhoid fever. Now it is import-
ant to point out that individual physicians
recognized that this type of control could not
be accomplished by the individual doctor but
had to be accomplished by governmental
bodies; and so physicians, themselves, were
the first to encourage and help to develop this
governmental activity in the prevention of dis-
ease. You know that today, as a result, there
is practically no typhoid fever for us even to
demonstrate to younger medical men, while
a generation or so ago it carried off a goodly
percentage of our population.
Then came, a little later, recognition of the
relationship of carriers of infection by insects;
and again the medical profession heartily
helped to develop control of disease through
the elimination of breeding places of mos-
quitoes and flies and by the screening of
homes to protect individuals from infected in-
194
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
sects ; and m that way we have practically
eliminated yellow fever, malaria, and similar
insect-borne diseases. This type of public
health activity received full support of the
medical profession, although it very obviously
eliminated disease and reduced medical prac-
tice. It is worthwhile to stop a moment and
ask why this type of public health activity ob-
tains so fully and readily the support of the
medical piofession? I believe the reason is
that it dealt largely with environment ; and I
think in the development of our thesis if we
will keep this in mind we will see the gradual
shift, and possibly an explanation for the
change of attitude on the part of doctors.
The second phase of public health activity
concerned itself more with prevention of dis-
ease by protecting the individual. Into this
category we would place activities for the pre-
vention and control of small-pox, diphtheria,
seal let fever, and measles. Diphtheria, you
know, can be prevented by the immunization
of individual patients, not by control of the
environment. Of course, the classical ex-
ample of this type of activity is the control of
small-pox. Here we are dealing with a con-
siderably different type of public health ac-
tivity. The purpose again is to prevent dis-
ease and to postpone death, but it is accom-
plished not by the control of environment, as
was pointed out in the first phase, but by
dealing with the doctor’s patient or prospective
patient directly. Vaccination has been carried
on largely by the individual physicians. How-
ever, with the recent development of hospital
clinics, and, more particularly, medical depart-
ments in boards of education, the tendency
has been to vaccinate children, without charge,
at public expense, irrespective of the financial
status of the child s family. More recently,
there has been introduced the prevention of
diphtheria through immunization by toxin-
antitoxin. Again physicians and the organ-
ized medical profession lent themselves en-
thusiastically to propaganda for the preven-
tion of disease through treatment of the indi-
vidual. It was obvious that the effect of this
kind of public health activity would be
markedly to reduce medical practice which
came from the treatment of this rather fre-
quent and serious disease of childhood. In the
zeal to protect children against disease, it was
recommended in many cities and states that
this immunization be carried out at public ex-
pense in clinics established by the health de-
partments or boards of education. This plan
meant free treatment, irrespective of the finan-
cial status of the family. In some places the
community itself employed a single physician
to administer the treatment ; but this last men-
tioned activity is a type of public health ac-
tivity which, to my mind, should become part
of the newer medical practice and should not
be carried on through free clinics, even though
the administering physician is paid.
The function of a public health department
should be to stimulate an interest in the medi-
cal profession to carry on this newer kind of
medical practice, and to arouse an interest in
the public to have the children promptly and
properly immunized. I know that this is a
much more difficult and slower way of getting
children immunized, but I somehow feel that
public health departments are breaking faith
with the medical profession and, in the long
run, will injure the cause of public health if
they do not insist that this phase of the pre-
vention of disease through treatment of the
individual shall be carried on by the individual
doctor rather than by public departments. It
must be said, however, that the attitude of
many physicians has been the very reason or
excuse, if you will, for public departments
carrying on this work. Many physicians have
not taken an interest in the newer methods of
prevention and actually have been indifferent
to or antagonistic toward such methods.
The third phase of public health activity
may be described as dealing with personal hy-
giene. It has to do with education of the in-
dividual in the art of living, and in the in-
dividual s control of his own environment. The
purpose of this type of public health activity
is much more than the prevention of disease
or the postponement of death. It has for its
object an increase of the individual’s health-
fulness and vigor. In a larger sense, its pur-
pose is the individual’s happiness through
physical well-being. It includes prenatal care,
infant hygiene, preschool hygiene, mental hy-
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
195
giene, the more modern development in school
hygiene, annual examination of adults, and so
on. In this group of public health activities
we have again developed a type of work for
the physician which the doctor, steeped in tra-
ditional medicine, has hardly considered medi-
cal practice. It has no morbid anatomy, it has
no pathology, it does not consist in the dis-
covery of diseased organs, it cannot be carried
on by the writing of a prescription. It con-
sists very largely of advice, of teaching a per-
son what the normal individual should be like
and is capable of, how he should eat, sleep and
live.
The development of public health activities,
then, has run from the control of environment
to the education of the individual in the art
of living, together with protection of the in-
dividual from disease by immunization. If
we will consider for a moment the history of
medicine, I think we shall be able to see why
it is that certain physicians are unable or un-
willing to adjust themselves to what must be-
come part of the newer medicine, if the doc-
tor, as we know him today, is to survive or if
he is to render the fullest service to humanity.
We need only look at medicine less than a
century back to note the great change which
has come over medical practice. Then, the
doctor felt that his whole purpose was to dis-
cover the disease from which the patient suf-
fered. The etiology of disease was too in-
definite to permit any rational therapeutics,
and so the scientific doctor felt that it was
quite beneath him to concern himself with
anything more than an accurate diagnosis. As
Jacobi expressed it, in describing medicine as
he was familiar with it in Germany around
1850 : “The best a patient could expect was
to be auscultated by Schoda and autopsied by
Rokitansky.” Toward the end of the last
century, as a result of work by Pasteur,
Ehrlich, and Koch, the etiology of disease be-
came clearer and therapeutics developed its
more rational basis. In addition to our interest
in morbid anatomy and physical diagnosis,
therapeutics became a well-established and ac-
cepted part of scientific medicine. Physicians
eagerly used antitoxins for diphtheria, tuber-
culin, vaccines, and the many different meth-
ods for specific treatment which developed as
the result of the scientific work of that period.
But during the past 25 years, medical educa-
tion and training have quite naturally been
given over entirely to study of the pathology
of disease and its treatment. A few men have
recognized that much disease can be prevented, »
but it has been practically impossible to famil-
iarize all physicians with this newer knowl-
edge, or to arouse a general interest in its ap-
plication. I think the attitude of certain
physicians toward the more modern practice of
medicine, which should include every possible
method for furthering human welfare, wheth-
er it be by education or by the prescrib-
ing of a drug or by the administration of an
antioxin, can be understood, if we think
of the medical profession as being made up
of individuals some of whom have been ar-
rested in their development at one or another
period in the development of the art and
science of medicine. Lombroso, in his study
of criminology, has explained the antisocial
conduct of individuals by pointing out that
their conduct is only antisocial because they
are apparently living in a former stage of
civilization. Those people who are considered
criminals in this generation or century would
be considered normal with similar conduct
several generations back. So it is with physi-
cians.
It is very natural that physicians should
think of the practice of medicine as dealing
only with the recognition and healing of dis-
ease, but it becomes necessary to point out that
unless they recognize also that, we have reach-
ed the point where the public demands it be
educated in the prevention of disease, in per-
sonal hygiene, in development of the fullest
vigor and health, the public will obtain this
instruction from other sources. We must re-
alize that society in America is organized on
quite a different basis from that of a genera-
tion ago. There are enormous foundations
eagerly awaiting the opportunity to subsidize
large community efforts, first for the preven-
tion of disease, but not far off for the treat-
- ment of disease also. Public departments na-
turally will respond to pubic demand. There
are today in public health departments men
196
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
who feel it is their duty to protect the public
against disease. If they find the individual
physician indifferent or antagonistic to assum-
ing the role which is offered, it, of course,
will be assumed by public departments.
Public health activities, then, have had a
» two- fold effect. They have eliminated dis-
ease, itself, but they have replaced it by a new
type of medical practice. The future develop-
ment of medical practice and public health ac-
tivities will depend upon the attitude of physi-
cians and the organized medical profession.
If it becomes sufficiently aware of the trend
of public health activities and satisfies the
community that it can be protected through
the private physician, there will be less ten-
dency to place the new public health activities,
which deal with individual protection, in the
hands of public departments. Welch, in his
second Sedgewick Lecture in Boston, summed
up this question as follows : “I should like to
refer very briefly to a matter which seems to
me of serious concern to modern public health.
This is the lack of sufficient active participa-
tion of the general medical profession in public
health activities, especially as developed in this
country. The fault is on both sides. There
has been encroachment upon the field of the
private practitioner and there has been a lack
of sympathy and cooperation with public
health officials and with health programs on
the part of practitioners. There can be no real
lasting success of efforts to promote the health
of the people and to prevent disease without
the active sympathy, support and participation
of the medical profession. How this is to be
more largely secured merits the most serious
consideration.”
HEALTH DEPARTMENT GROWTH
IN NEW JERSEY*
D. C. Bowen,
Director of State Department of Health,
Trenton, N. J.
Public health work in New Jersey, as a
function of state and local governments, is 53
years old. The first State Board of Health
•(Read at the 164th Annual Meeting of the Medi-
cal Society of New Jersey, Atlantic City, June 13,
1930.)
was created in 1877, and 10 years later the
law requiring local hoards of health was en-
acted. In this one small state there are now
561 local health boards. They consist of more
than 2800 members and employ about 580
persons on full time and 760 on a part time
basis. Appropriations from public funds for
the work of these 561 boards in 1929 amount-
ed to over $2,000,000. It should be borne in
mind, for the purpose of this paper, however,
that many of the 1340 employees are clerks
and secretaries and that only 119, or 21%, of
the 561 municipalities and townships employ
licensed health officers, and that three-fourths
of the money is spent in the 50 cities and
towns having over 10,000 population.
This vast number of separate bodies is the
result of a law that requires each municipality
and each township, no matter how small in
size or population, to have its own public
health organization. Four decades ago, such
boards may have been able to carry out the
best sanitary practices of that day. Today,
many of them are not.
In the field of medicine, the advances of
the last half century have been monumental.
As a result of some of these advances and
those in other professions, health departments
have grown in the amount and complexity of
work delegated to them, as well as in numbers.
Their activities now include control of com-
municable diseases, supervision of milk, food
and water supplies, recording of vital statis-
tics, regulation of plumbing, inspection and
abatement of nuisances, health promotion, and
a multitude of related matters. They may
adopt ordinances and enforce rules and regu-
lations relating to a wide variety of subjects.
Public health laws of New Jersey fill a
volume of nearly 400 pages and the State
Sanitary Code adds 30 more. Wise, indeed,
is he who can find his way through such a
maze of words and not get lost. A number of
these laws impose exacting duties on physi-
cians. In the busy round of practice, it is
easy to understand how some of these duties
are occasionally forgotten by doctors. It has
occurred to me that a small booklet setting
forth these requirements of law in compact
form might be helpful to you. Such a book-
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
197
let is now being prepared by the State Depart-
ment of Health.
One important change since 1S77 is in our
point of view toward communicable diseases.
Emphasis used to be placed on human sur-
roundings and on filth, in the belief that dirt
bred disease. This idea probably helped to
make us a cleaner race but it fixed attention on
visible and often harmless dirt instead of on
the unseen kind which we know now is often
deadly.
With the knowledge that each communicable
disease has a specific, living causative agent
and that sources of most of these diseases are
persons, not things, our whole attitude to-
ward disease prevention and control has
changed. The spectacular retreat of typhoid
fever, tuberculosis, diphtheria, malaria, plague,
and yellow fever are some of the results of
this newer information and viewpoint.
Knowledge as to how disease producing or-
ganisms enter the body, battle with the cells
and secretions of the body, leave the body and
are carried to other persons has put the
struggle against this group of diseases and their
partial control, at least, on a scientific basis.
For this reason, if for no other, common
sense and good judgment alone no longer fit
a man for board of health work, as they might
have done 40 years ago. The efficient sanitary
officer today must know something of bacteri-
ology, chemistry, epidemiology, engineering
and statistical methods, and also appreciate
the practical problems of the dairyman,
butcher and restaurant proprietor. He should
also possess the diplomacy that will enable him
to use this knowledge. Health officers and in-
spectors were formerly sanitary policemen, in-
tent on arbitrarily enforcing sanitary regula-
tions. The modern official, if he is really
modern, is a teacher and leader in sanitation
and hygiene. He has found that with most
people, force is likely to fail in the long run
and education is apt to succeed.
The effect of the changes just pointed out
has been unmistakable in the growth of both
state and local health departments in New Jer-
sey. I have been connected with public health
work in this state for 39 years, and with the
State Department of Health since 1903. In
that time, I have seen the Department grow
from a little group of 15 employees to an or-
ganization which is exceedingly crowded in 19
office rooms and 3 laboratories. Its office and
field staff now numbers 155 and this number
is not sufficient to carry out in a satisfactory
way even the mandatory duties imposed by
law.
On many occasions, small groups, to whom
the department’s organization and duties were
being explained informally, have expressed
surprise and unexpected interest in these mat-
ters. Since the physicians of the state are
probably the largest group of persons with
which the department deals directly and in-
directly, I believe the members of this society
will be interested in a bird’s-eye view of the
organization of the State Department of
Health, which may have seemed an imper-
sonal sort of thing but which is really com-
posed of men and women whose interest and
problems often run parallel to your own.
The work of the department is carried on
by 10 divisions or bureaus. They are the
Bureaus of : General Administration ; Local
Health Administration; Food and Drugs;
Vital Statistics; Engineering; Venereal Dis-
ease Control ; Child Hygiene ; Bacteriology ;
Chemistry ; Public Health Education.
The Bureau of Administration is defined
by its name ; it is the business branch of the
Department.
The Bureau of Local Health Administration
is one with which many of you have direct con-
tact. Epidemiologists connected with this bu-
reau investigate and help control epidemics and
smaller outbreaks of communicable diseases,
and assist local health and school boards to
inaugurate and conduct toxin-antitoxin and
Schick test clinics, make sanitary surveys and
deal with most of the problems which annoy
local health boards until they ask for help.
This bureau also receives, tabulates and studies
reports of cases of communicable diseases filed
by doctors with local reporting officers and by
them transmitted to the department. Certain
contagious diseases that occur on dairy farms
are dealt with by men from this bureau. Other
duties too numerous to mention, together with
those just enumerated, make greater demands
198
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
on the small staff of this bureau than it can
possibly meet. The Public Health News,
which I hope you all read and enjoy, is also
prepared in this bureau. The 2 district health
officers, stationed at Freehold and Pitman, re-
port through the chief of this bureau.
Contrary to popular belief, much of public
health work is not medical. One of the ear-
liest and still very important parts is sanitary
engineering, which has contributed very greatly
to progress in disease control and sanitation.
The engineering bureau of the State Depart-
ment of Health carries out duties placed upon
the department by 16 different laws. Approval
of sewerage systems, disposal plants and water
supplies are among these. The word “ap-
proval” may suggest a simple procedure but
actually it demands a great deal of investiga-
tion and study. The examination and ap-
proval of plans for nearly $10,000,000 worth
of construction a year is in itself a time con-
suming and extremely exacting duty. Investi-
gations of stream pollution are conducted by
this bureau and also a check on the operation
of the 704 water treatment and sewage treat-
ment plants in New Jersey.
Three laboratories are maintained by the
department ; 1 for bacteriologic examination
of specimens from communicable disease cases.
.1 for chemical testing of food and drugs, and 1
for testing water and sewage. With the facili-
ties and services of the first, you are doubtless
more or less familiar. Specimens from known
or suspected cases of communicable diseases,
which many of you submit in special contain-
ers deposited by the department throughout
the state, are grown and examined in this
laboratory. Its work has increased each year
and reached the impressive' total in 1929 of
60,000 specimens.
Our chemists examine a wide variety of
products for detection of adulteration and
misbranding. These products range from
Hamburg steak, artificially colored cakes, can-
ned products and milk, to soft drinks, drug
preparations and extracts. Testimony in court
takes an appreciable amount of time of the
men who make the analyses. An important
branch of this laboratory is conducted aboard
ship; on the department’s floating laboratory
boat, “The Inspector”. Sanitation of the shell-
fish grounds of New Jersey is secured partly
as a result of tests of the water and of oysters
and clams themselves at Delaware Bay,
Maurice River, Wildwood, Tuckerton, Rari-
tan Bay and other producing areas.
The third portion of the laboratory, which is
really a part of the engineering division, tests
water and sewage. The thousands of samples
examined each year come from public water
supplies, state institutions, parks, schools, sum-
mer camps for boys and girls, bottled waters
sold in New Jersey, private wells and springs
believed by local boards of health to be pollut-
ed, and from sewerage systems and sewage
disposal plants. Both chemical and bacterio-
logic tests are carried out. The laboratory co-
operates with the Fish and Game Commission,
State Department of Conservation and De-
velopment, State Department of Public In-
struction, and Interstate Commerce Commis-
sion, in testing water used for public or semi-
public purposes.
Inspection of foods, and establishments
where foods are stored, handled, manu-
factured and sold, is made by representatives
of the Bureau of Food and Drugs. Dairies,
pasteurizing plants, creameries, ice-cream
plants, slaughter houses, cold storage ware-
houses, bottling plants, egg breaking establish-
ments, hotels and restaurants are among these.
Samples of foods and drugs are collected
regularly for laboratory examination. Alert-
ness of this bureau uncovers dangerous prac-
tices and products from time to time, stories
of which occasionally appear in the public
press.
When you sign a birth or death certificate,
perhaps you have wondered what happens to
the document before it reaches its final resting
place. Perfection is hardly too strong a word
to apply to the system by which these im-
portant records, gathered by over 560 local reg-
istrars, move with precision on the tenth day
of each month to the Bureau of Vital Sta-
tistics of the State Department of Health for
final study, classification, tabulation and filing.
The originals are bound in books, about 6
in. thick, and filed in fireproof vaults in the
State House. Searching old records and pre-
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
199
paring certified copies of these filed certificates
for employment, pension, passport and other
legal purposes, keep 3 persons constantly
busy. About 150,000 certificates are received
yearly and approximately 7,000,000 are now
preserved in the vaults. A transcript is made
of each marriage, birth and death certificate
filed in the State Bureau of Vital Statistics,
and forwarded to the Bureau of Census,
Washington, D. C., for use in compiling re-
ports on vital statistics issued by the United
States Government.
Qiild welfare appeals to all normal people
and the growth of the child hygiene movement
in the last decade has been phenomenal. New
Jersey’s progress in this field has attracted
wide attention. The Bureau of Child Hy-
giene now supervises the work of 132 nurses
carrying on a unified program in 400 com-
munities (not municipalities) in the state. Its
activities, however, have reduced the number
of midwives in the state and greatly elevated
their standards of practice. Boarding homes
for children, and maternity homes are under
its supervision, and courses of lectures on
normal children, for nurses and teachers in
training, help to keep before them the ideal
of healthy, happy childhood.
After receiving silent treatment for cen-
turies, venereal diseases have been attacked
since the beginning of the World War in
much the same way as other communicable
diseases. The Bureau of Venereal Disease
Control carries on a two-edged program. On
the one hand, it attempts to get cases reported
and treated and to learn the name of the per-
son who transmitted infection in each case so
that she (or he) may also be treated. Many of
you doubtless are active in the medical part
of this effort. Demonstrations of newer meth-
ods of treatment are given occasionally to
medical groups in different parts of the state.
On the other hand, the Bureau seeks to in-
form parents and older boys and girls as to
the facts regarding sex and venereal diseases,
so that ignorance may play a lessening part in
the social problem as time goes on.
Three phases have marked the evolution of
public health since its birth 50 years ago. The
first was sanitation ; the second, disease pre-
vention ; and the third, health conservation.
In this last phase, education is of signal
value and the most recently created division of
the Department is the Bureau of Public Health
Education. Newspaper stories emanating
from this bureau have been used throughout
the state during the last year and a half.
You have noted that the State Department
of Health has been able to expand its work
to conform in some measure to progressive
ideas of public health service. What of local
health departments ?
In cities and wealthy towns where appro-
priations for public health work are sufficient
to employ trained personnel, the services of
the health department have kept pace, in gen-
eral, with our knowledge of sanitation and hy-
giene. Approved activities for the protection
and promotion of health are carried on with
rather limited budgets, to be sure, but in ways
which throw about residents and visitors to
these communities creditable safeguards
against preventable ill health. In most bor-
oughs and townships, however, little progress
has been made, because of lack of funds. Per-
sonnel competent to carry out the activities
just ' mentioned is more costly than a small
community can afford. Conversely, most
boroughs and townships do not have suffi-
cient board of health work to require the full
time of even 1 individual.
Organized public health work might be car-
ried on in a state the size of New Jersey in
either of 2 ways. One method would be to cen-
tralize all responsibility in a State Department
of Health and perform the necessary services
through a network of employees spread over
the state. Such a system is contrary to the
principle of local self government, and, so far
as I know, is not recommended nor desired
by anyone. Another method places responsi-
bility on local bodies and makes the State De-
partment of Health a supervisor, with power
to act in case a local board fails. The State
Department of Health could also act in inter-
municipal matters and could assist local de-
partments through its specialists and labora-
tory facilities. The latter is the system adopt-
ed by the legislature 43 years ago. It should
be a good system but it breaks down if local
200
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
boards cannot carry their share of the burden,
and that is just what has happened in hun-
dreds of places since public health work be-
came such a complex, technical procedure.
What can be done about it? The only prac-
tical correction that I can suggest is to en-
large the local sanitary district until it can
support, at reasonable per capita cost, a health
department that is able to function. The same
problem has been met by several other states
in this way. In the south and west, usually
the county has been the unit because the
county, rather than the town, is actually the
local political unit in those areas. I doubt if
the county would be satisfactory in all cases
in New Jersey. Our counties vary so widely
in size, population and in the number of cities
and large boroughs which already have excel-
lent health departments, that difficulties would
surely arise in reshaping a state-wide reorgan-
ization on county lines. Several rural counties
in New Jersey might each comprise a unit for
health administration. In other sections, a
combination of adjacent small boroughs to
make a district of 20,000 to 30,000 population
might be better. Cities and large towns should
maintain their own health departments. Legis-
lative action will be necessary to make the
change suggested or any other change which
will set up workable health departments in
suburban and rural districts. To draw a bill
which will meet the needs of the state as a
whole and insure a smoothv operating public
health organization throughout New Jersey is
no small task. To secure legislative approval
of the needed changes may be difficult. But
the effort should be made, for in the midst
of a world moving rapidly toward public
health achievements of a high order, many of
our small communities are practically standing
still, in so far as official health departments
are concerned.
No group knows better than the physicians
of the state the difference between the care-
fully planned and executed programs of our
better health departments and the haphazard,
bungling efforts of the poorer ones when con-
fronted by emergencies. When a plan of re-
organizing local health work has been drawn
up and meets with your approval, will you,
the medical men of New Jersey, lend your
strength toward placing the public health ser-
vices of this state on the high plane which pre-
ventive medicine, sanitary engineering, chem-
istry and bacteriology make possible?
STATE DEPARTMENT OF LABOR IN
RELATION TO THE PUBLIC AND
THE MEDICAL PROFESSION*
Henry H. Kessler, M.D.,
Newark, N. J.
The Department of Labor was organized
and established by law in 1904. Most of you
are familiar with the department, particularly
in its workmen’s compensation and its rehabili-
tation aspects. The department, however, did
not begin as a workmen’s compensation bureau
nor as a rehabilitation division ; it started os-
tensibly to overcome the exploitation of child
labor, which had become rampant in the years
just before 1904, when the department was
established with a Commissioner of Labor at
its head and 2 Factory Inspectors, who were
to seek out and investigate any violations of
the Child Labor Law. Since that time the de-
partment has been enlarged so that at the
present time there are 9 bureaus and about
175 employees to carry on its different func-
tions. The first Commissioner of Labor was
Col. Louis T. Bryant, who functioned
from 1904 to 1923. From 1923 to 1929, Dr.
McBride was Commissioner of Labor. The
present incumbent is Col. Charles Blunt.
The Department of Labor is now composed
of the following Bureaus: (a) General and
Structural Inspection Bureau and Explosives ;
(b) Sanitation and Hygiene; (c) Women and
Children; (d) Statistics and Records; (e) En-
gineer’s License, Steam-Boiler and Registra-
tion Inspection; (f) Employment and Wage
Collection; (g) Workmen’s Compensation;
(h) Rehabilitation. Each bureau is in charge
of a head, who is responsible for the activities
of his particular department.
*(Read at the 164th Annual Meeting of the
Medical Society of New Jersey, Atlantic City,
June 13, 1930.)
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
201
In order to carry out the functions of the
Bureau of General and Structural Inspection
the state has been divided into 22 districts, in
each of which a factory inspector is charged
with the responsibility of investigating viola-
tions of the State Labor Laws ; fire apparatus
must be investigated, elevators must be prop-
erly guarded, as well as machinery, approaches
to stairs and fire-escapes must be kept clear at
all times, healthful working conditions must
prevail, ventilation and exhaust systems, must
be installed where necessary, buildings hous-
ing more than 25 people must be provided
with a standard system of fire signals and fire
drills must be held. Accidents are investi-
gated as to their occurrence, so that others
may be prevented in the future. Where mines
and quarries are located, these must be prop-
erly safe-guarded. Assembly halls are inspect-
ed if no building supervision is at hand.
Wherever explosives are stored these must be
maintained in accordance with departmental
rules. In addition, illegal employment of
women or children is investigated by the fac-
tory inspector.
The department also conducts a safety
museum, in Jersey City, where is maintained
an exhibit of safety appliances and safety
methods, which is open to the general public
at all times. Safety talks are given from
time to time, at different plants, by members
of the department.
The function of the Bureau of Hygiene and
Sanitation is very closely allied with that of the
Department of General and Structural Inspec-
tion. The same factory inspectors, in addition
to their previous duties outlined, must pay
special attention to health hazards, such as
dust, fumes, excessive heat, poor lighting or
ventilation, washing and toilet facilities, and
any special health hazards that may exist.
These are all regulated by law, and this is of
particular importance in this state because of
the wide and extensive existence of industrial
hazards, particularly in the northern part of
the state. No less a person than Sir Thomas
Oliver, of England, several years ago, when
here, stated that within a 25 mile radius of
Newark existed the largest geographic area
in the world from, the standpoint of specific
industrial health hazards.
A little over a year ago there was estab-
lished in Newark an Occupational Disease
Clinic. In view of the unusual publicity and
unusual number of cases in the field of occu-
pational disease that we had to deal with in
previous years, it was thought wise to establish
a clinic where such cases might be studied,
men might be examined, and a certain amount
of information might be disseminated to lay-
men and to the medical profession. In the
past year and a half over 800 persons have
been examined in this clinic. Cooperation of
the medical profession has been urged, in the
reporting of occupational diseases, for the
specific reason that as soon as a case is re-
ported to the State Department of Labor a
Factory Inspector or the Deputy Commis-
sioner will immediately investigate that case.
If poisoning or a special health hazard does
exist, he will take measures to remove it, cor-
rect it, or eliminate the plant.
In the northern part of the state, history has
been made in the field of occupational dis-
ease. Radio-active poisoning was put on a
definite, pathologic basis by Dr. Martland, and
recently a new form of occupational disease,
that of silicosis, has been giving us a great
deal of thought and trouble.
In addition to these bureaus, there was re-
cently established, under the leadership of
Mrs. Summers, a Bureau of Women and
Children, to investgate violations of the law
pertaining to women and children in factory,
mercantile, field and home work. Especial in-
terest in the migratory child labor problem
exists at the present time. As you know, New
Jersey has been progressive in the regulation
of labor by women and children. We have a
Child Labor Law which provides that no child
under the age of 14 may be employed, and no
child under the age of 16 may be employed in
specially hazardous work ; we have no night
work for women ; a 10 hour day law for
women; and an 8 hour law for children of 16
years and under.
The Engineer’s License Bureau supervises
licenses for steam boiler engineers, and steam
202
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
boilers are also investigated by the Depart-
ment of Labor.
The Bureau of Statistics and Records is
very important. Records are important in any
field of public endeavor, but they are es-
pecially so in the Department of Labor, par-
ticularly in the Workmen’s Compensation
Bureau, because rates of compensation and
premiums are passed upon and are based upon
the accurate statistics kept by this bureau.
The Employment Division conducts free
employment bureaus, licenses and regulates
private employment agencies, investigates the
extent and causes of unemployment, and also
cares for the claims of those who have been
refused payment of wages earned. Of especial
interest to the medical profession is the agita-
tion recently developed for the preemploy-
ment examination of domestic servants,
similar to that of food handlers for contagious
and venereal diseases. The Employment Di-
vision has been asked by several Boards of
Health to cooperate in refusing employment
to those who are found harboring disease. Only
c small number of municipalities, however, are
as yet cooperating. Of additional interest in
this Division is the regulation of commissary
camps, which are nothing more in many cases
than boarding houses that receive the privilege
of housing workers in rural sections. For
about 3 years these camps have been licensed
and gradually efforts have become successful
in securing higher standards of physical con-
dition. It was found that the State Health
Code set up regulations affecting these camps
only as to polluted water supply, the fire-
proofing of privies and cesspools and disposi-
tion of excremental matter. It was found also
that the state of Pennsylvania, through its
Labor Department, had developed a very ex-
tensive set of regulations concerning every de-
tail of these commissary camps ; so a similar
set of regulations has now been developed in
this state.
To the medical profession, the 2 divisions
of the Department of Labor that are of par-
ticular interest are the Workmen’s Compensa-
tion Bureau and the Rehabilitation Division.
Enough reference has been given to indus-
trial medicine and traumatic surgery yester-
day and today to give you a little insight into
the difficulties that exist and arise between em-
ployers and industry at large and the medical
profession.
The Workmen’s Compensation Law, which
is a munificent piece of social legislation, was
passed in 1911; New Jersey being one of the
first states to pass such a law. Unfortunately,
the Department of Labor, or perhaps for-
tunately, had nothing to do with the passage
of that law, and unfortunately the medical
profession was given very little voice in
making that law, so that we find today
a very anomalous situation : We find that
a contract exists between 2 parties, an em-
ployer and an employee, in which nothing
is said about a necessary third party — -the
medical profession, The Department is
charged with the responsibility of passing on
claims for industrial accident, determining the
awards for disability, passing on bills, etc. In
Newark, a Medical Bill Committee was es-
tablished in order to adjust these matters of
disputed medical service bills. This method
of handling disputed fees has been found to
be a happy solution. There are 3 men ap-
pointed to this Committee: Dr. Kraker repre-
senting the Essex County Medical Society,
Dr. Jackson representing the employers, and
myself representing the state. We meet once
a month. Bills are referred to the committee
for arbitration. The physician involved is
asked to appear at this informal meeting, and
we invite also a representative of the insur-
ance carrier or the employer. At this meeting
differences are ironed out, and in approxi-
mately 95% of cases the carrier is willing to
and usually does pay the bill or pay whatever
this Committee recommends, despite the fact
that we have no power in law.
In 1919, New Jersey passed the first Re-
habilitation Law. New Jersey felt that her
citizens were entitled to the same consideration
that war veterans received. When the Federal
Government passed a law for rehabilitation of
the disabled veteran, it felt that the tin cup
and the lead pencil were not the answer to
disablement. New Jersey felt the same, and
6 clinics were established in large centers of
population throughout the state where any in-
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
203
dividual who was physically handicapped by
virtue of disability, caused by accident or dis-
ease, could come for those services to which
the law entitled him. Those services meant
treatment, vocational training and placement
in remunerative employment if he could work.
In the past 10 or 11 years, since New Jersey
led the way in the field of rehabilitation, other
states have fallen in line, so that almost 40
states now have laws providing for rehabilita-
tion of physically handicapped persons. The
Federal Government assists some of these
states by subsidy of monies in order to speed
the work on. I have some slides here which
will demonstrate some of the rehabilitation
work and some of the rehabilitation cases,
which I would like to show you.
(Lantern exhibition.)
THE DOCTOR AND THE LAW*
Robert Peacock,
Mount Holly, N. J.
On the subject of the Doctor and the Law,
I want to speak of law enforcement, not the
law enforcement that has caused such an up-
heavel in the minds of the people of this coun-
try but the enforcement of laws concerning
your profession and the public health of the
state; enforcement of the laws of this state
not for restriction of the rights of its people,
but the protection of public health. The law
that keeps your profession on a higher plane ;
that rids the community of quackery. Quack-
ery is more detrimental to your profession and
the public health, than the radical red attempt-
ing to supress the functions of government ;
because if we do not have a healthy people
we cannot have a healthy government.
The gullible public is falling more each day
to these so-called “new ideas” of cures, and
gradually drawing from the care of doctors,
who are trained to cure and keep the public
healthy. Is it because your profession deems
its standards so high, that you are not educat-
*(Read at the 164th Annual Meeting of the Medi-
cal Society of New Jersey, Atlantic City, June 13,
1930.)
ing the public against these tenets of mal-
practice. while your opponents are spreading
propaganda throughout the. state advertising
their wares and condemning medicine? It is
your duty to start a campaign of education
among the people of this state to stamp out
these fakers in medicine; to have committees
of your state and county medical societies co-
operate with the State Medical Examining
Board which has this subject at heart, and
educate the public on this subject.
Medicine is- of all arts the most noble, and
the profession should be on a plane of nobility
and free from imperfections, and my duty as
attorney for the State Medical Board has
been to uphold the Medical Practice Law of
this state and try in my feeble way to keep
your profession on a holy plane, free from
violators who would practice this noble art
without license.
Hippocrates said in his oath : “As a physi-
cian I will keep this oath and this stipulation,
by an oath according to the law of medicine,
but to none others. I will follow that system
of regimen which, according to my ability and
judgment, I consider for the benefit of my
patients and abstain from what is mis-
chievous.” That same oath still remains the
duty of physicians to this day, and it is the
foundation of our law that life and health
are protected by the law of this state for the
benefit of its people, and to protect those who-
practice the noble art of medicine.
Instruction in medicine is like the culture
of the productions of the earth. Our natural
disposition is, as it were, the soil ; the tenets
of your teachers are, as it were, the seed; in-
struction in youth is like the planting of seed
in the ground at the proper season; the place
where the instruction is communicated is like
the food imparted to vegetation by the atmos-
phere; diligent study is like cultivation of the
fields; and it is time which imparts strength
to all things that bring them to maturity. Hav-
ing brought all these requisites to medicine,
and having acquired a true knowledge of it, it
is your duty to uphold the traditions of your
profession and be physicians in reality, and to
cooperate with those in authority to keep from
the profession those who do not hold this to
204
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
be the law, and without partiality prosecute
to the fullest extent those who violate the con-
fidence of the people and violate the laws upon
which your profession is founded. For that
purpose, the Legislature of this state has said
that to be a physician to practice in this state
certain qualifications are to be had before a
person can take the examination, others who
do not possess those qualifications are not en-
titled to take the examination and practice
medicine in this state.
Our law says that any person who shall use
the word “doctor” in connection with his
name and hold himself out as being able to
diagnose, treat, operate or prescribe for any
human disease, pain, etc., who does not have
a license to practice medicine from the State
Medical Board is violating the law of this
state. Our courts have passed upon this act
and have said that it is constitutional. A
chiropractor or osteopath cannot use the title
doctor. A chiropractor or osteopath cannot
•give electric treatments. A chiropractor can-
not use a concusser or a light to shine in the
eye. An osteopath cannot examine eyes. An
osteopath can only use his hands for certain
replacements. An osteopath or chiropractor
v cannot give medicines or prescriptions. A
chiropractor can only manipulate the spine, by
Land.
The Act sets forth $200 for the first viola-
tion, and $500 for the second violation, or in
the alternative a jail sentence. The Board can
revoke the license of a physician for the fol-
lowing causes : chronic and persistent in-
ebriety; criminal abortion; conviction of crime
involving moral turpitude; for publicly ad-
vertising special ability to treat or cure chronic
or incurable disease, or where a license has
been obtained through fraud of any kind.
From the year 460 B. C. physicians were or-
ganized into a corporation or guild, with regu-
lations for the training of physicians, and with
an esprit de corps and a professional ideal
which with slight exceptions can hardly yet
be regarded as out of date. The physician
must not only be prepared to do what is right
himself, but also must be willing to uphold
the law and prosecute others who do not up-
hold the same. He must report violators of
the law and generally cooperate with those
in authority to enforce it. Law enforcement
is a duty that is incumbent on all of you; whe-
ther you believe in it or not the duty rests with
you to protect the public from the tenets of
those who have no license to practice medi-
cine and impose on a public that is always
willing to grab some new novelty in the way
of healing or some other faker who advertises
his wares without any foundation for the good
of the public. Law enforcement is an ideal
not a fallacy, and it cannot be enforced with-
out cooperation. The State Board has its
corps of investigators and spends time and
money to protect the profession, but it can-
not find all the violators through its own
searching. Complaints are made to the Board
by people who are not doctors, more so than
bv the doctors themselves, so you see the gen-
eral public is exercised over these violators;
and if the public is exercised, you as physi-
cians should be more so, not only to protect
your profession but to protect the public. Our
fore-fathers said the Constitution was to pro-
tect life and property. Property’s greatest as-
set is health. Howr can it be better protected
than by prosecuting those who have no right
to encroach on the title of property?
1 he State Medical Board is working for
your benefit and devotes its time for the bene-
fit of the profession, and it must of necessity
know where to locate those w'ho traverse the
law. in order to prosecute, so I call on you, as
citizens who believe in upholding the law, for
your full cooperation in law enforcement in
this matter in this state, and in doing this,
gentlemen, you will not suffer the most hon-
orable of all professions to be debased into a
sordid lucre traffic by the fakers outside of this
profession who have neither license nor
knowledge to practice. Especially is it your
most sacred duty to yourselves and your pro-
fession to help prosecute these violators ; it
constitutes an important part of justice, and
if cooperation is not forthcoming from you
doctors then this and other abuses of your
profession will continue and the people will
suffer from a lack of enforcement.
For a moment I will call your attention to
some classes of fakers we are called upon to
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
205
prosecute. I will not mention names but the
files are in my office and will corroborate what
I cite:
“Dr. L.” — in Ocean County — claimed to
free the body from toxic poisonings and said
it was necessary to create “new pores” in the
body. He proceeded with a woman to insert
new pores in her body. He had a machine
with 26 needles in it and from the woman’s
shoulders to her heels he placed this machine
drilling holes in her body. She had 1000 in-
fections in her body, and subsequently died ;
and her husband died within 3 hours as the
result of the shock.
A man, “Mr. C.”, of Bergen County, claimed
to have a cure for tuberculosis and he obtain-
ed $10 per bottle for this so-called cure, which
a subsequent analysis showed contained only
lard, molasses and vinegar ; and he accum-
ulated a fortune from sales of this sure cure
for tuberculosis.
Another “Mr. G.”, of Hudson County, had
a sure cure for cancer and diagnosed and treat-
ed conditions as cancer, and he even claimed
that our investigators had cancer. Analysis
showed his medicine was nothing more than
plain chocolate in wafers.
“Mrs. W.”, of Gloucester, was a practicing
midwife without license ; no care was taken of
the children’s eyes after birth ; 3 children went
blind and 1 mother died as a result of her
ignorance.
“Mr. W.”, son of a minister of Union
County, was an “expert on foot diseases” ; he
studied in a correspondence school, and ruined
quite a few people’s feet in his ignorance.
Druggists are treating gonorrhea and dis-
eases of that character, and in Hudson
County one druggist had blank prescriptions
signed by 2 doctors, and he treated patients
and gave medicine with doctor’s names on the
bottles, and these doctors admitted they never
saw the patients.
“Mr. J.”, of Essex County, practicing chiro-
practic, was convicted and then started prac-
ticing dentistry and was convicted of both
violations.
“Mr. W.”, of Newark, claimed to be an
“expert in stomach diseases” and had quite a
practice, and the only thing he gave was an
ordinary cereal in cans, which he said he ob-
tained from Germany.
Certain chiropractors are now trying electric
treatments in connection with manipulations
by hand, which is a violation of the law as our
courts say chiropractors can only manipulate
the spine with the hand ; there have been
several convictions of these men. Osteopaths
are doing the same thing, claiming they are
also “naturopaths” ; and many convictions of
these people have been obtained by your state
board.
Fake advertising is another evil which is
being corrected ; both within and without the
profession. Fake certificates from other states
are also presented to the Board, which call
lor constant supervision and investigation.
It will be a grave indictment of you men,
as physicians, if you fail to cooperate in this,
the most serious of crises. I crave for your
earnest consideration of these facts, for an in-
fluence in quickening of your profession in
this matter ; in deepening your seriousness
and in assisting the State Board to carry out
the law of this state.
A very few words more and I will be
through. Those words are words of hope.
Indeed, if I have said anything that seemed
to you to be bitter, it has been in a spirit of
friendliness, to help me in a cause I have at
heart. I know this cause will conquer in the
end for it is an article of faith with me to
protect the health of our people of this state
from quacks. I know well it is not for me
to prescribe the road to success of this under-
taking, but faith in my work impels me to-
speak according to my knowledge, feeble as it
may be and rash as the words may sound, for
every man who has a cause at heart is bound
to act as if it depended on him alone. I am
practicing the things I have asked you to do;
it is a pleasure to work for you and try in my
feeble way to bring results and uphold the
dignity of your profession, and to prosecute
those who violate the law, and with this all
in mind you have asked me to speak to you
as a friend. I could do no less than to be
open and fearless before you, my friends.
So, in closing, I plead with you to start a
system of education among the people of this
206
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
state and nation to combat this insidious
propaganda of these so-called modern cures
and faith healing and other fakes and quack-
ery, to combat the propaganda of those who
piactice such methods. To strengthen the
law of this state so that for a second or third
violation of the Medical Act the sentence will
not be a fine but imprisonment in jail of not
less than a year; as fines will not stop the
illegal practice of medicine in New Jersey.
Discussion
Chair vi(i7i McBride. I wish to express our ap-
preciation to all the gentlemen who have render-
ed these very excellent papers. They are now
open for discussion.
Dr. Frank. W. Pinneo (Essex): We are to be
congratulated, I believe, on the progress which the
government is making in New Jersey, and in
ha\ ing the Assistant Attorney-General enforce, with
such an ardent spirit of cooperation, the law,
Which is so often flagrantly violated. From the
way the law is now worded, in spite of the ardor
of the enforcing authorities, they often cannot
prosecute from lack of the required evidence of
specific deeds done besides the misuse of the title
“Doctor”. However, we can help to get this evi-
dence, and with the combined forces always on
rthe alert to the evils, which are well known, the
advancement ought to be great. We, in Essex
County, where the evil is perhaps more rampant
than anywhere else in the state, are willing to co-
operate, and we want to say we appreciate the
very great help that the Board of Medical Ex-
aminers is giving and the marked improvement
that has been made in our county.
Dr. J. Bennett Morrison (Newark): The address
of the Assistant Attorney-General is going to go
a long way toward remedying illegal practices in
this state. He may not know it, but for a great
many years we have been discouraged and handi-
capped, in prosecution of these cases, by the
negligence, if not refusal, of the county legal au-
thorities to help; but if the medical profession can
know that from now on, if these cases are reported,
they will be brought to justice through the office
of the Attorney-General, it will go a long way to-
ward ridding us of illegal practitioners in the
state of New Jersey.
Dr. Charles B. Kelley ( Tersey City) : The amount
of material that was covered here this afternoon
caused me to take enough notes to really produce
a paper of my own; however, inasmuch as I am
most familiar with the work as outlined in Mr.
Peacock’s paper, I shall confine my remarks to
that paper with the one exception of Commissioner
Ellis’ statement in regard to Dr. Renner’s work
at Skillman Village. There is one thing that he
has done, and that is to insist upon his medical
staff being licensed men. It has been and still is
in parts of this state the custom for institutions,
state, county and municipal, to have as full-time,'
paid physicians, for an indefinite number of years,
men who never had a license, some of them unable
to obtain a license, and your state, county and
municipal wards are being treated by physicians
who cannot go out and treat the general public.
Now, Dr. Renner has been particularly careful in
that respect so that at Skillman there is now, I
believe, nobody who is not a licensed physician.
Unfortunately, in other institutions there still are;
and the way by which these institutions keep these
physicians is simply the clause that was put in
the law to cover interns; it was never meant to
allow physicians to stay in institutions indefinitely.
Only recently we issued a license to a doctor, the
head of one of our big institutions, who has been
the head of that institution for 12 years. He was
well entitled to a license, we found out, but he had
novel secured it, and yet he had been in the mean-
time, President of his County Medical Society.
In regard to Mr. Peacock’s paper, the Medical
1 lactice Act of the State of New Jersey is un-
doubtedly one of the strongest in the union, and
it has become that by the activity of the various
Attorneys-General, since enforcement has been
placed in the hands of the Attorney-General, a
matter of some 10 or 12 years. Prior to that time
the County Prosecutor was the one who was sup-
posed to enforce this law. There was no en-
forcement. When it was placed in the hands of
the Attorney-General there was activity, and from
my own personal knowledge, the Medical Practice
Act has been very largely built up by the activity
of Mr. Peacock’s predecessor, Mr. Grover C. Rich-
mond, of Camden, who obtained many excellent
court decisions, and it has been further strength-
ened since the work has been in the hands of Mr.
Peacock.
The other person in this state who is doing more
to enforce the Medical Practice Act than any one
other individual is the Inspector of the State Board
of Medical Examiners, and I certainly feel that
she is well entitled to tribute, not only from me
but from the entire profession in the state. Mrs.
Frances Wilkinson is a woman who seems par-
ticularly adapted to that kind of work, and as In-
spector of the Board she is just as vigilant as
Mr. Peacock, the prosecuting attorney.
The functioning of the Board of Medical Examin-
ers could be improved. The Board meets only once
a month. The secretary is only a part-time man;
consequently a large part of the work drifts into
the hands of lay people, and the profession of the
state is being protected by virtue of the fact that
the lay woman who is the chief employee of the
Board is extraordinarily capable.
The pi ofession thinks that a report of the vio-
lations is all that is necessary, and that it is an
easy matter to obtain convictions; and now after
hearing from Mr. Peacock I know how much re-
porting there is going to be done, and if you don’t
get action I want to let you know why. The prim-
ary reason is that a man is always innocent until
he is proved guilty, and to prove a violator guilty
is a hard job. There are all sorts of investigators
and investigations necessary. The Courts have
ruled that a given number of treatments must be
given. The treatment must be corroborated, the
testimony must be corroborated, and it is only
right that the judge will give the defendant the
benefit of any doubt. In certain types of cases
it is utterly impossible to prove the charge. In the
cases of alleged abortion it cannot be done as the
pei son upon whom the abortion has been perform-
ed will not appear, and certainly you cannot send
investigators in for that work. Injections of vari-
cose veins — I wonder how many of the profession
ho have varicose veins would go and have them
treated by quack hypodermic injections of all sorts.
Still it is necessary for investigators to be so treat-
ed if the case is to be proved. There are innumer-
able obstacles to the enforcement of the law, and
the greatest obstacle of all is the limitation of
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
207
funds. We have a very small corps of investi-
gators. Outside of Mrs. Wilkinson, our inspector,
we have to depend entirely upon 3 or 4 investi-
gators who only work part time and who receive
a very nominal amount of money for services ren-
dered. For every case that is prosecuted the cost
is something like $75 or $80. At the utmost the
Attorney-General will get $200 back. The average
is cut down by virtue of the fact that a certain
number go to jail for a day, and by other factors.
The general cost of enforcement always shows a
deficit at the end of the year, and it was largely in
order to obtain funds for maintaining a more
strenuous enforcement, such as Mr. Peacock has
outlined, that the Board advocated an annual reg-
istration fee. Of course, the history of annual
registration we all know. We may have annual
registration some day, but that is another ques-
tion that need not be discussed now. However, if
you are going to send in a lot more complaints, we
will do our best to investigate them. In the mean-
time, as far as the actual legal end of it is con-
cerned, the state takes care of that wonderfully
well by giving us such competent men as Mr.
Peacock.
Dr. Henry O. Reilc (Atlantic City) : I appreciate
Mr. Peacock’s coming here and making a clear
statement to us as to what his Department is
willing to do. I am very appreciative because I
have heard of how ably he is supporting the Medi-
cal Practice Act, and is prosecuting offenses against
that act. I do want to take exception, however,
to one or two things that he said, and ask him
to look a little further for some information on
this subject. From certain necessary implicatioiis
from some of his remarks, I gathered that he laid
the obligation upon the medical profession to do
this prosecuting and informing. I doubt whether
that is an obligation that properly belongs to the
medical profession, but it is an obligation which the
medical profession has accepted almost from the
beginning of time. He implied that the medical
profession should always give information con-
cerning quacks and charlatans in the state, re-
ferred to the lay information received, and im-
plied that we had been negligent in that sort of
thing. I doubt if 10% of the information that has
come to his Department has been from lay or-
ganizations. I am under the impression that 90%
of this information does come from the profession.
I doubt very much if any layman has presented
any complaint and information except in the few
instances where that layman has been individually
“stung” or some intimate friend or relative of his
has been seriously defrauded.
He also puts upon us the obligation of educating
the public regarding quacks and charlatans'. I am
sorry he did not hear Dr. Fishbein’s lecture last
night. What other body than the Medical Society
is doing anything toward education of the public
with regard to quackery and charlatanism? This
educational work the medical profession has teen
carrying on for a long time, is carrying on con-
stantly; in contrast to the great public institutions
of the country that are constantly aiding the
quacks and charlatans. I hope, Mr. Peacock, you
will deliver your story to some of those organiza-
tions. While we are fighting quackery and charla-
tanism, and trying to educate the public to under-
stand the falsity of quackery, 90% of the maga-
zines and newspapers in the country are spread-
ing broadcast the advertisements of these very
quacks and charlatans that you talk about; and,
worse than that, we heard last night the extent
to which the radio stations are supporting them.
You have only to tune in tonight on any station
you please, and you will probably pick up one or
more of those patent medicine talks; certainly you
can pick up one any time during daylight hours.
Those are the 2 great “educational institutions”
of the country- — the newspapers and magazines,
and the radio — and they are backing the quacks
and charlatans all the time; and so far as I know,
the medical profession is the only institution that
is carrying on an educational campaign to instruct
the public about such dangers.
Mr. Peacock meant well and honestly in what
he said, and we all know he has proved himself
to be our friend, but I want to set him straight
on those points.
Dr. E. P. Darlington (Burlington) : It seems to
me that this State Medical Society should go on
record in opposition to the Act that permits our
State, County and other Municipal institutions to
employ unlicensed practitioners. The inhabitants
of those institutions would not be allowed to em-
ploy those physicians were they not in the insti-
tutions, and a man in an institution should have
as good care, or have the same care, as he could
employ on the outside. Those physicians cannot
have general practice so they ought not to prac-
tice on the patient after he goes into an insti-
tution.
Dr. Fred J. Quigley (Hudson) : I thoroughly en-
joyed hearing Mr. Peacock’s talk, and certainly it
is pleasant to know that the State Board has en-
joyed and does enjoy such splendid cooperation
from the Legal Department of the state.
There is one question that I have in mind, that
I would like to have Mr. Peacock’s opinion on, and
possibly Dr. Kelley’s, and that is the matter of
offenses against the Medical Practice Act so far
at it affects second and third offenders.
I don’t know whether Mr. Peacock will agree,
but it seems to me that one of the weaknesses is
that the penalties for second and third offenders
are not sufficient. Dr. Kelley tells us of the tremen-
dous expense entailed in obtaining evidence against
these quacks, that for each case it means 5 or
6 treatments before they can obtain a conviction;
and after they have obtained convictions there
have been quite a number of cases where within
a month they are practicing again, and then the
state has to go through the same procedure, the
offenders receive a slightly higher fine, and then go
out again and continue practicing; and the same
proposition has to be met again.
I have sometimes wondered, whether there was
any method by which these quacks, after con-
viction could be enjoined from practicing again,
and if they continue to practice, instead of again
being fined, whether appropriate action could not
be taken under contempt of court proceedings.
Mr. Robert Peacock: No injunction would lie.
Dr. George N. J. Sonvm&r (Trenton): I am sure
that most of the membership know of the action
taken by the Mercer County Medical Society this
year in relation to state employees on a full-time
and part-time basis with maintenance, to declare
that private practice by them after a certain date
shall be unethical.
I have arisen to speak on this occasion merely
to pay a compliment to the Department of Insti-
tutions and Agencies and . to its representative,
Mr. Ellis, who spoke here today, and to offer
thanks for the cordial treatment accorded a
Committee from our County Society. This action
208
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
caused a great deal of excitement in the county at
first, but the Committee, with the aid of the De-
partment of Institutions and Agencies, has been
able to adjust the matter. The Department treated
us very well, and agreed that our points were
well taken, and I presume so far as the state of
New Jersey is concerned, this practice will prob-
ably be abolished within the time limit set by our
county society.
Dr. John F. Hagerty (Newark): I would just
like to give expression to a thought that occurred
to me while listening to all these papers. It is very
instructive to learn of the manifold agencies there
are in this state concerned with the protection of
our lives, the preservation of our health and of
our comfort. It would seem as if every detail of
our lives was being watched over and guarded
by agencies in this state, for which we are all
thoroughly appreciative. Yet, in spite of all that,
we learn through Mr. Peacock that there are still
many people who barter away their lives, their
health and their comfort by entrusting their lives,
when ill, to irresponsible practitioners. It is hard
to understand this, and I felt that possibly if what
we have learned this afternoon could be brought
home to our people, could be emphasized over and
over again to our people, just what the various
agencies throughout the state are doing, how much
concerned they are with the lives and health of the
people of this state, and what they are doing to
protect them, it might help a bit in discouraging
ether people from resorting to the help, such as it
is, of these irresponsible practitioners. I think it
is a very splendid thing, Mr. President, to realize
what is being done by the various agencies
throughout the state for the people of this state.
MALNUTRITION IN CHILDREN; AN
ATTEMPT AT STANDARDIZATION
OF A DIETARY*
L. Charles Rosenberg, M.D.,
Newark, N. J.
Statistics regarding the incidence of mal-
nutrition made by various authorities indicate
that about one-third of the children of this
nation are nutritionally below par. Wood esti-
mates 15-25% of the school children as being
undernourished. Perlman states that in a re-
cent survey conducted throughout the United
States there were found 5,000,000 cases of
malnutrition in children — almost one-fifth of
the entire number of school children in the
nation. T hat as a nation we have been neglect-
ful of our greatest asset — the child — has been
more and more recognized in recent years.
♦(Abstract of paper read before the Pediatric
Section of the Medical Society of New Jersey, at
the Annual Meeting, in Atlantic City, June 12,
1930.)
Roberts expresses her opinion very well when
she says : “We must admit that we have little
reason as a nation to be conceited over the
stock we are producing.” She adds: “It is
true, moreover, that our standard of nutrition
is higher than that of some other countries
though poorer than many.” Statements such
as these make the problem appear worthy of
our serious consideration and effort. So im-
portant does the problem of child welfare and
protection seem to the government that some
months ago President Hoover, at a White
House Conference, initiated an investigation
of the present situation. One of the larger
committees was charged and is active with the
study of child nutrition.
Much investigation has been done, especially
during the last decade, in an attempt to estab-
lish a standard dietary for children suffering
from malnutrition. We also have confined
ourselves to this phase of the problem, but
have devised a dietary which is a decided de-
parture from the usual one employed in this
condition. This paper is a discussion of an
experiment conducted on a group of mal-
nourished children who were put on this
special dietary to test its nutritional value.
Relation of Disease to Malnutrition
In dealing with malnutrition one must not
over-emphasize the importance of diet to the
neglect of other factors. Nevertheless, in a
considerable proportion of undernourished
children, a cause for the nutritional state can-
not be detected. It is especially in this type
of case that the outstanding method of cor-
recting the condition is the dietary treatment.
While it is not the primary object of this
paper to enter into a discussion of the rela-
tion between disease and malnutrition, stress,
however, must be placed upon the fact that, if
a thorough enough study (including painstak-
ing physical examination, laboratory tests of
the blood, urine and stools, metabolic rate, oph-
thalmoscopic examination and radiographs) of
the children suffering from malnutrition were
made, the great majority would show disease
or defect somewhere in the body responsible
for the condition. This view of the relation-
ship between disease and malnutrition is borne
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
.i09
out by the difficulty we had in selecting a
group of disease-free children suitable for the
experiment conducted. We were offered ap-
proximately 200 underweight children from
which to select a group for our experiment.
Some were excluded because x-ray examina-
tion of the chest showed active tuberculosis, 4
had a 4 -)- Wassermann test, some had rheu-
matic carditis, some were suffering from in-
testinal parasites, others from obvious en-
docrine dysfunction, many from badly dis-
eased tonsils, from carious teeth, from ne-
phritis, pyuria, vulvovaginitis, chronic otitis
media, tracheobronchial adenopathy and para-
nasal sinus disease, so that by the time we
had examined the entire group there were only
56 children left who we felt reasonably sure
were not suffering from any disease or defect
and on whom the experiment could be con-
ducted.
Development of a New Dietary in
Malnutrition
During the course of clinical observation an
attempt was made to trace back the type diets
that yielded the healthiest looking children,
and contrariwise, the diets that yielded chil-
dren in a state of undernutrition. It appeared
convincing that those children that were ex-
cellent examples of well-nourished individuals
were the ones who consume ample quantities
of milk, whole grain cereal products, an abun-
dance of fresh vegetables and much fresh
fruits, meat not being a prominent article of
the diet ; whereas those that composed the
group of malnourished, consume large quan-
tities of flesh foods and comparatively little
milk, little or no whole grain cereal products,
fresh fruits and fresh vegetables sparingly.
Further thought and observation seemed to
verify this impression.
The average dietary of the infant under 2
years of age is one in which flesh foods are en-
tirely omitted, or, if present, are in so small
a quantity that little credit can be given to
them, and yet malnutrition today is compara-
tively rare in infants. It is chiefly a condition
of older children. This would indicate that
the dietary changes made during the transition
into childhood are not entirely successful.
Many parents to whom I have spoken empha-
sized the fact that until 2 years of age their
children were pictures of blooming health, but
after this period gradually developed into a
state of malnutrition. It was elicited that radi-
cal changes had taken place in the dietary,
flesh foods and other foods were being intro-
duced to the partial or complete exclusion of
milk, whole grain cereals, fresh fruits and
fresh vegetables.
While many children of the older age groups
coming under observation were .splendid look-
ing specimens who have been given meat since
infancy, in nearly all these cases careful ques-
tioning revealed the fact that it was used so
sparingly and so infrequently that it could
not be responsible for the excellent physical
development. Many pediatrists, I am sure,
have seen fine examples of physical develop-
ment in children who have persistently refused
to eat meat because of a natural dislike for
flesh foods. The vegetarians bring up their
children on meatless diets. It has been my
privilege to have been able to examine a large
group of these children. While hitherto I
had considered the vegetarians an erratic group
of individuals, repeated observations showed
these children to have such splendid posture,
firm musculature, high color, excellent teeth,
glossy hair, a good layer of subcutaneous fat,
bright eyes and a high degree of energy, that
I was forced to give the matter of a meatless
diet serious consideration and to experiment
along this line.
Discussion of Experimental Dietary
The dietary consisted of about 1 quart of
certified milk and of many milk products.
Whole grain cereal products were served 3
times a day, fresh vegetables twice a day, both
raw and cooked being served, fresh fruits
twice a day, freshly ground nuts and large
quantities of legumes to keep the protein in-
take high. Moreover, the legumes are com-
plete proteins, and are a good source of the
amino-acids essential for growth. No meat,
poultry or fish was used in any form. No
animal broths were given. Neither gelatin nor
eggs were included. The purpose of omitting
eggs was to confine the animal protein of the
dietary to milk alone.
210
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
There are certain factors which we desire to
stress. The diet meets the caloric need, cov-
ers the requirements of fat, protein, and car-
bohydrate, for the age group. It is high in
essential mineral content, contains the essen-
tial amino-acids, is rich in all the known
vitamins, is decidedly prominent in alkaline-
ash foods, and embraces all the “protective
group” of foods.
By the use of certified milk and the avoid-
ance of meat the diet is obviously low in bac-
terial content. The reason for using so much
whole wheat is because of (1) its ability to
build up hemoglobin; (2) its richness in min-
eral content, and (3) its richness in vitamins.
(4) It is well known that a diet of milk and
whole wheat cereal with no other addition but
a small amount of sodium chloride will sup-
port growth of experimental animals through
as many as 21 generations, and that the last
members of the family will be more vigorous,
larger and stronger than the first generations.
Experiments performed on animals by Rose,
Yahlteich and Bloomfield have proved the
value of whole wheat in producing an increase
in hemoglobin. Morgan and Barry point out
the importance of whole cereal, particularly
wheat and rice, as a possible source of the
vitamin complex B (B + G). It is noteworthy
in this connection that in an experiment they
conducted on a group of underweight chil-
dren they were able to show decided increases
in weight and height through the addition of
wheat germ to the diet.
At the beginning of the experiment an at-
tempt was made to equalize the caloric intake
of both groups and weigh the foods, much as
is done in diabetic or ketogenic diets. This,
however, was found to be highly impracticable.
The appetite of the different children varied,
and the same child’s inclination varied on dif-
ferent days according to its disposition. Fur-
thermore, it was felt that children should be
given as much as they wanted, and then after
several weeks of observation the average in-
takes could be weighed and measured. This
plan was carried out. The procedure of or-
dering weighed and measured portions of
foods for children is not practical nor possible
in daily practice.
All foods used were very fresh, no canned
articles of food being employed. No white
bread at all was served. The spaghetti used
was prepared from whole wheat flour; the
rice was unpolished ; to the gravies, sauces and
soups an autolysed extract of yeast was added,
imparting a flavor resembling meat ; cakes and
puddings were made of whole grain cereal
products ; the mayonnaise was eggless ; no ice-
cream was given because of its high bacterial
content. Brown sugar and maple sugar were
used for the additional mineral and vitamins
they provided; only certified milk was served.
Extra care and precautions were taken in
selecting and preparing the vegetables. Only
very fresh vegetables were used, for their
flavor is decidedly better. The vegetables were
placed in parchment paper and steamed, be-
cause by this method of cooking they retain
their entire mineral content and also their
flavor. The raw vegetables were always con-
sidered a treat by the children. They were made
attractive by shredding them extremely fine by
machine and this was always done immediately
before serving, so that they would not become
dried out. The various colors, particularly
when the food was served on colored plates,
appealed to them.
Because the children had always had meat
previously, it became necessary to devise sub-
stitutes that resembled meat, both in taste
and appearance. This was easily accomplish-
ed by serving the foodstuffs as “roasts”,
“steaks", “croquettes”, and “meat balls”, cov-
ered with tasty sauces, the chief constituent
of these substitutes being legumes.
In addition, varied and unusual dishes were
devised, as vegetable broths, vegetable stews,
cold creamed soups, vegetable potpourri,,
squash pancakes, buckwheat vegetable mixture,
braised vegetables, vegetable turnovers, glaced
vegetables, cakes and cookies made of whole
wheat flour, pudding of whole cereal grains
combined with nuts, fruit and cream, vege-
table gelatin desserts, chocolate pudding made
of whole wheat flour instead of corn starch and
crullers made of whole wheat flour. The possi-
bilities of substitutes and combinations are
both interesting and unlimited.
A large variety of breadstuffs was used —
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
211
whole wheat, whole wheat with nuts or raisins,
whole wheat muffins, bran muffins, whole
wheat rolls of all sorts, rye bread, corn bread,
corn muffins and Graham bread.
Summary
Two groups of underweight children, each
consisting of 25 subjects, were selected and
matched according to age, height, weight, and
sex. One was put on a special dietary (ex-
perimental) and the other on a good average
American dietary (control), and the progress
of the 2 groups was compared at the end of a
period of 6 months.
The essentials of the experimental dietary
were a quart of certified milk daily, a variety
of nuts, whole grain cereal products 3 times
a day, fresh fruits and fresh vegetables twice
a day, with the exclusion of meat and eggs.
The weight increase showed that the experi-
mental diet proved superior from the stand-
point of rapidity as well as of the permanence
of its results. The weight increase in the ex-
perimental group at the end of the 6 months’
period was 32% greater than in the control
group. The height increase was 24% greater
in the experimental group than in the control
group.
The more extensive anthropometric data es-
tablished the validity of the weight-gain study,
while further technical treatment of these data
in relation to the arm and calf girth and sub-
cutaneous tissue over biceps, corroborated the
superiority of the experimental dietary.
The results show that the experimental
dietary proved to be superior for girls to a
greater extent than for boys. It is very likely
that psychic factors played an important role
in the production of this sex difference.
The blood studies showed no difference in
progress for the 2 groups. The urinary analyses
indicated a much lower acidity for the ex-
perimental group than for the control group.
The psychometric studies and x-ray studies
of the bones were not conclusive. The stools
■of the 2 groups showed a decided contrast
in physical appearance, with a diminution
in the total number of bacteria in the
stools of the experimental group. The ni-
trogen balance studies indicated a slightly
better retention for the experimental group.
The experimental dietary was proved to be
rich in vitamin B complex, as indicated by our
studies on rats.
The importance of the vitamin B complex
content in a child’s dietary is stressed. Both
diets, as tested on rats, were shown to contain
sufficient vitamin B to effect a complete cure of
deficiency symptoms with the same rapidity.
Discussion
Dr. Arthur Heyman (Newark) : Dr. Rosenberg
has given a tremendous amount of thought and
energy to the preparation of this excellent paper.
Any physician who treats children cannot help
but be impressed with the importance of his sub-
ject. He needs no statistics to emphasize in his
mind the prevalence of malnutrition in children
apparently free from physical and mental defects.
The diet used by Dr. Rosenberg is not original in
itself but is ingeniously conceived in the selection
of individual dishes and in their preparation. After
carefully analyzing the dietary, one can easily un-
derstand exceptional weight-gains in the experi-
mental group. There are so many elements which
we know to be highly conducive to good nutrition.
Certified milk, which forms a large part of the
menu, has long borne an excellent reputation, es-
pecially in the city of its birth. We have all had
personal experience with its growth producing
qualities and appreciate the reasons for its supe-
riority over pasteurized milk.
Dr. Rosenberg mentioned the glossy hair of the
experimental children. Dr. Wherry has shown this
effect by feeding certified milk to his house-dog,
producing a glossy hairy coat, and then undoing
his work by changing to pasteurized milk.
The value of whole-grain products is clearly
shown by the references in this paper. I should
like to ask Dr. Rosenberg how he explains their
failure to stimulate hemoglobin production?
Fresh fruits and vegetables so generously sup-
plied, with their rich content of easily available
foodstuffs, vitamins and ash, undoubtedly con-
tributed much to the improvement of these chil-
dren.
Samuel Kugelmass, in the April 1930 number of
the. American Journal of Diseases of Children, feed"
ing rats a diet rich in base-forming foods, as is
Dr. Rosenberg’s, demonstrated that it accelerates
the rate of growth, development, metabolism and
activity.
I am glad to see that Dr. Rosenberg points out
in his summary that exclusion of flesh foods plays
only a small part in the success of his dietary
since, exclusive of meat and its products, the con-
trol and experimental diets differ so markedly.
In conclusion, let me congratulate Dr. Rosenberg
on his courage in tackling such a difficult study
on actual children instead of adopting the easier
method of animal experimentation, and on the
thoroughness and painstaking exactitudes of this
work.
Dr. F. 1. Krauss (Chatham): I would like to ask
Dr. Rosenberg how much milk the children in the
control group were given? I am very partial to
giving a small portion of meat. I feel that meat
once a day is a boost to their vitality, and I like
to give them a minimum of a pint of milk a day.
Under these control diets, if these children had no
212
JOURNAL 0/ THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
milk or very little milk, by increasing the milk
the same results might be gotten. I would like
to ask whether Dr. Rosenberg feels that the re-
sults are due to an increase of calories by giving
more milk, or to an increased vitamin diet?
Dr. Charles Rosenberg (Closing) : Roth groups
of children had an equal intake of milk in their
dietary and they had about the same amount of
calories. I think the thing that did the trick was
not merely the exclusion of meat but the fact that
we freely used whole-grain products, combined
with a quart of milk a day. I do feel, however, that
eliminating meat was one of the great factors.
Dr. Heyman asks why it is if all experimenta-
tions show that these products, particularly whole-
wheat, build up the hemoglobin, that we do not
have any contrasts between the groups. We had
some difficulty with the hemoglobinometer during
the course of the work and I think that is where
the trouble lay. The children on the experimental
diet, despite the lack of contrast, had better color
than those of the control diet, and their general ap-
pearance was better.
ESSENTIALS IN INFANT FEEDING*
Percival Nicholson, M.D.,
Philadelphia, Pa.
Gradually there has evolved out of the
tremendous amount written on the subject of
infant feeding, some fairly definite facts and
underlying principles, so that it has become
much more of a science and less of an art.
The physician confronted with a feeding
problem has so many methods of treatment
that he is often confused as to which method
or food to employ in a given case. This paper
is written to aid in determining a definite
course in a normal feeding case, with no aim
to handle the special or unusual cases which
require different forms of treatment. Even
in the normal case there are many individuali-
ties, as to frequency of feeding, strength of
food and quantity of food to be given, and it
is not always possible to at once start with the
best type of feeding, but at the outset any
food must of necessity be an experimental or
trial formula, often requiring considerable al-
teration to suit the individual infant’s needs.
The type of infant feeding used, often mars
or makes the child’s future health. It is not
only of importance to have a healthy looking,
well-nourished infant, desirable as that may
*(Read at the 164th Annual Meeting of the Medi-
cal Society of New Jersey, Pediatric Section, Atlan-
tic City, June 12, 1930.)
be, but what is more important is to have an
infant supplied with the proper food ingre-
dients in a balanced relation, one to anothr.
so as to produce the best cells and tissues pos-
sible, so that not only will he gain and grow
well, but, in addition, have the ideal physical
and mental developments with the greatest
possible resistance to disease. It is a great
responsibility when one stops to consider that
even the brain power of the future adult, as
well as his general physical health and endur-
ance, largely depends on the character of his
previous infant feeding and care through
childhood.
It is a fact, definitely proved on many
occasions, that for the normal baby, good
breast milk from a healthy mother, supplies
the type of food, both as to quantity and qual-
ity, best suited to develop the ideal infant. In
the beginning of modern infant feeding, an at-
tempt was made to imitate in cow’s milk form-
ulas the exact percentage of fat, carbohydrate
and protein found in normal breast milk. These
earlier attempts at scientific feeding, while a
decided advance over previous methods, were
found to be deficient in many respects and
have been abandoned. Recently, food for the
infant has been regulated more to fulfill the
physiologic needs of the child’s digestion. As
a result of numerous researches in the physi-
ology and chemistry of digestion, new facts
have come to light. Without burdening you
with all the details of the various and long
pieces of research which have led up to the
present knowledge of infant feeding, I shall
try to state rather briefly the more salient
points on which infant feeding depends.
In the normal breast fed child the ingre-
dients are in proper amount and relation one
to another for ideal growth ; the problem being
mainly one of seeing that the infant receives
his food in the right quantity, at the right speed
and the correct feeding interval, to satisfy all
his growth needs. As breast milk reaches the
stomach it is coagulated into a fine, soft floc-
culent mass and the whey or liquid portion
quickly separates, and as soon as the stomach
contents reach a certain degree of acidity the
pyloric sphincter opens and allows the acidulat-
ed whey to pass rapidly on into the intestines,,
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
213
while the soft curd is more slowly digested, the
stomach being emptied in 2 to 2 y2 hours. The
most important part of gastric digestion is in
relation to the protein of breast milk, which
being largely lact-albumin contains practically
no buffer substance. By a buffer substance we
mean a substance which is capable of producing
a combination with the gastric hydrochloric
acid, thus lessening the available free hydro-
chloric acid in the stomach. The emptying
time of the stomach depends on the rapidity
with which the gastric contents reach a cer-
tain degree of concentration of free hydro-
chloric acid. As the proteins in breast milk
contain practically no buffer substance and
during the gastric digestion produce a fine
flocculent curd, allowing free access of the
gastric juices to all portions of the food, there
is very efficient gastric digestion with rapid
emptying of the stomach. The thoroughly
acidified gastric contents, on reaching the duo-
denum, further stimulate the intestinal mu-
cosa which, in turn, produces secretin, an acti-
vator of biliary and pancreatic secretion, to
insure good intestinal digestion.
Of all the constituents in breast milk, the
most important is protein, for it is only
through protein that new cells are produced ;
neither fat nor carbohydrate being able to
cause growth. Another very important fact
in considering the digestion of breast milk
protein is that it is made up of a number of
component amino-acids which are essential to
normal growth. Thus 2 facts stand out prom-
inently: first, breast milk protein, by its lack
of buffer and formation of flocculent soft
curd, favors both rapid and efficient gastric
and intestinal digestion ; and, secondly, that
the protein, or growth element, of breast milk
•contains the kind and amount of amino-acids
best suited to the infant’s growth. In good
breast milk mineral salts are found in normal
amounts. Antirachitic vitamin D and antiscor-
butic vitamin C, however, are deficient and
should be supplemented. B vitamin is in small
quantities, and it is therefore necessary to
give additional B vitamin in some cases.
As a substitute for breast milk, when arti-
ficial feeding is necessary, good cow’s milk
is almost universally chosen. So, let us con-
sider for a moment in what way the protein
of cow’s milk differs from that of breast milk.
Holt and Fales conclusively showed that as the
amino-acids in cow’s milk protein varied in
number and amount from those of breast
milk, to obtain the necessary amount of the
essential amino-acids of breast milk it was
necessary to supply twice the amount of cow’s
milk protein.
In the digestion of raw cow’s milk protein,
we find 2 very important differences from that
of breast milk, namely, a high buffer sub-
stance, and the formation of a firm tough
curd in the stomach. When raw cow’s milk
reaches the stomach a certain amount of free
hydrochloric acid combines with the buffer
substance, and, as a result, the gastric acidity
is lowered and the emptying time of the stom-
ach delayed. The formation of a large, tough,
firm curd further slows digestion and delays
gastric evacuation.
As the protein is the essential growth ele-
ment we must determine the protein need of
the infant and build our formulas around it.
The various food elements, fat, carbohydrates
and protein, have their own particular func-
tions to perform, for which they are best
suited and are so interrelated that to produce
the ideal results they must be in proper bal-
anced relation one to another. The relative
amount of fat and protein found in cow’s milk
is a good one but the carbohydrate should be
increased. In ideal digestion, Holt and Fales
have shown that about 35% of the calories
should come from the fat, 50% from the car-
bohydrate, and 15% from protein. As, for
example, a formula of 3% fat, 7.5% carbo-
hydrate, and 2.8% protein has such a relation-
ship, and gives 21 calories to the ounce, the
same as good breast milk. To fulfill the pro-
tein needs of an infant, 1.5 gm. cow’s milk
protein per pound of body weight are required
or, the equivalent, the protein contained in 1^2
to 1^4 oz. of whole milk per pound of body
weight in the entire day’s food.
After determining the basic protein re-
quirement it is important to supply the infant
with the necessary amount of fluid, namely,
3 oz. per pound of body weight for the first
3 months, 2J4 oz. per pound during the next
214
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
6 months, and 2 oz. per pound in the last 3
months of the first year. The amount of fluid
necessary in 24 hours includes the milk in
the formula. It is an easy matter to divide the
total quantity in amounts suitable to the in-
fant’s gastric capacity relative to its age. The
infant’s physiologic capacity per feeding can
be counted as 2 oz. more than the age esti-
mated in months up to the sixth month, after
which no further increase is made, but the
formula is supplemented with other more con-
centrated types of food. The feeding inter-
val is made as long as possible, to give the
correct amount at each feeding and use the
total 24 hr. fluid. In normal infants, never
feed less than 3 hours, and when possible 4
hour intervals.
Having made up our formula with whole
milk to satisfy the infant’s protein needs, and
as in whole milk fat is in a proper balanced
relation to the protein, both fat and protein
requirements are fulfilled. Then, we add
enough carbohydrate to make up 50% of the
total calories. The fluid, fat, carbohydrate
and protein needs are met, and such an amount
of whole milk contains enough mineral salts
for all requirements.
Such a formula contains sufficient fat vi-
tamin A, but the C, or antiscorbutic, vitamin
is deficient to a varying degree, so this has to
be added either as orange juice, lemon juice
or strained canned tomato juice. B vitamin
may or may not be sufficient, so that recently
it has become customary to add such a vi-
tamin either as malted cereal germ, or brew-
er’s yeast extract. Vitamin D is deficient in
all milk, so must be added by giving cod-liver
oil, newer preparations of rayed egosterol, or
ultraviolet light treatment.
Finally, the 24 hours’ food for the normal
infant should contain from 45 to 55 calories
per pound of body weight.
In addition to satisfying all the above food
needs the formula should be made as digest-
ible as normal breast milk, or as nearly so as
possible. The digestion and assimilation of
the food itself require a considerable number
of calories at best, so that the more easily
digestible we can make our formula, without
replacing normal gastric and intestinal func-
tion, the better. Additional calories are thus
made available for growth.
Fortunately, there is a means of reducing
the buffer substance in cow’s milk and alter-
ing the character of the curd formation, so
that the degree of free hydrochloric acid at
the height of digestion and curd digestion ap-
proximates very closely that when breast milk
is given.
Boiled cow’s milk acidulated with proper
amount of either acetic, lactic, citric or hydro-
chloric acid reduces the buffer substance and
gives a fine flocculent curd, so that it is di-
gested with about the same ease as breast milk.
In varying degrees the same lessening of the
buffer and the production of a fine, flocculent
curd is also produced by the heating and
processing of the protein by boiling, evaporat-
ing, or drying of milk, with or without acidu-
lation. This was amply proved by the work
of Marriott, Hess, Brennemann and others,
and we now have available a method of mak-
ing the protein element of cow’s milk nearly as
digestible as the protein of breast milk.
One is often asked as to the advisability of
routine feeding of acidulated food for normal
infants, who in many cases could handle a raw
milk formula with comparative ease. As acid-
ulation of the formula aids greatly in diges-
tion it would seem the logical thing, especially
during the first 5 months, when the demands
on digestion are great and the organs of di-
gestion immature, to acidulate the formula
for the following reasons:
( 1 ) Acidulation causes a fine precipitation
of protein, rapidly and easily digested, when
prepared from either cold boiled milk or evap-
orated unsweetened milk ; whereas the curd
of raw milk is large, tough and slowly di-
gested.
(2) The buffer substance in the protein of
acidulated cow’s milk is so reduced that the
gastric acidity and the emptying time of the
stomach approximate very closely that when
breast milk is fed. On raw mixtures the buffer
causes a very decided slowing of gastric evac-
uation.
(3) In acidulated food the acid is suffi-
ciently high to inhibit bacterial action prevent-
ing fermentation and diarrhea. The formula
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
215
keeps well even when refrigeration is poor or
the food is carelessly handled.
(4) The gastric contents of acidulated milks
are more acid on leaving the stomach than
when raw milk is given. This increased acid-
ity accomplishes 3 things: (a) Gives a greater
stimulation to the flow of secretin, which in
turn causes better biliary and pancreatic secre-
tion and, as a result, better intestinal diges-
tion. (b) The increased acidity helps in the
solution and better absorption of calcium and
phosphorus, (c) It inhibits bacterial growth
in the intestines, of a fermentive type, and
permits a higher amount of carbohydrate
being fed without gastro-intestinal disturb-
ance.
Tf one uses organic acids, lactic, citric or
acetic, which are quickly broken down to car-
bon dioxide and water, the acid base equilib-
rium is not disturbed and an alkaline type
of stool is produced, putrefactive in odor and
of a slightly constipating type. An acidulated
milk supplies a food which physiologically is
digested with almost as much ease as breast
milk, but does not replace gastric or intestinal
function as peptonized food does. As the aim
is to produce a food as digestible as breast
milk and at the same time supplying all the
necessary food ingredients, in a proper bal-
anced relation, acidulated formulas should be
advocated for routine feeding.
Kerlev, in 1923, used evaporated, unsweet-
ened milk, acidulated by bacterial inoculation,
for the treatment of diarrhea. Shortly after-
ward, Marriott brought out his epoch making
article on acidulated milk treated with lactic
acid. When Hess and Matzner, in 1924, ad-
vocated the use of lemon juice to acidulate
milk, I used both cold boiled milk, and un-
sweetened, evaporated milk acidulated by this
means, in preference to either the culture
method of Kerley or lactic acid as used by
Marriott. The work of Brennemann seems
to show that plain, unsweetened, evaporated
milk produces a fine flocculent curd, almost as
digestible as breast milk, comparing favorably
with the unsweetened, evaporated milk acidu-
lated by lactic acid as advocated by Marriott.
I prefer, however, unsweetened, evaporated
milk, acidulated by lemon juice, to either plain
unsweetened milk or that acidulated by lactic
acid, because:
(1) It affords an easy way of giving an
antiscorbutic, which neither of the other meth-
ods supplies.
(2) The acidulation produces a better
emptying time of the stomach than plain, un-
sweetened, evaporated milk.
(3) The citric acid in lemon juice inhibits
bacterial growth and makes the mixture safe
even in hot weather, lessening the liability to
diarrhea. Kerley mentions that he w^as unable
to treat diarrhea cases satisfactorily with un-
sweetened, evaporated milk, no matter how
modified, until it was cultured with lactic acid
bacilli, after which it was as valuable as pro-
tein milk.
(4) The gastric contents being more acid
when they reach the intestine, give a better
absorption of calcium and phosphorus than
when evaporated, unsweetened milk is used
without acidulation.
(5) The lemon juice mixture has a less acid
taste than the cultured mixtures advocated by
Kerley, and is much less troublesome to pre-
pare. It is also less acid to taste than w’hen
the lactic acid mixtures of Marriott are used;
hence it is taken better and is less liable to
cause vomiting.
(6) Lemon juice produces a finer curd, and
hence more digestible protein, than either
plain, unsweetened, evaporated milk, or evap-
orated milk acidulated with lactic acid.
In addition to the above facts, unsweetened
evaporated milk has certain other advantages
over raw milk clearly brought out by Mar-
riott :
(1) It is relatively very cheap.
(2) Percentages are very uniform, being
approximately twice the strength of good raw
cow’s milk (fat 8%, sugar 10%, protein 7%),
and is safeguarded by federal inspection.
(3) In certain cases it affords a means of
giving very concentrated, easily digested food.
(4) Processing of the protein, due to homo-
genization and heating, aids in cases of eczema
and allergy to cow's milk protein.
(5) It is a nonproprietary food, available
anywhere.
(6) Although there is a slight precipitation
216
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
of calcium and phosphorus into insoluble
salts, this deficiency is off-set by the fact that
these elements are present in 3 times the
amount found in breast milk and are dissolved
by the digestive juices. It requires less acidu-
lation to maintain a good gastric acidity, with
evaporated unsweetened milk, than when
boiled milk is used.
(7) Fat being homogenized is thereby made
into a fine emulsion, more easily digested.
As a routine in normal infants, I am accus-
tomed to place the baby on a formula a little
below his caloric needs, as it is important to
give a food within the infant’s digestive abil-
ity, but to maintain his full fluid requirements.
The strength of food is increased as rapidly
as the digestion will tolerate, up to the infant’s
protein requirements, and enough carbohydrate
added to balance the food so that it gives 21
calories to the ounce, as in good breast milk.
Enough of the food is given to supply 45 to
55 calories per pound. In normal babies I
prefer food giving 21 calories to the ounce,
as there is less danger of protein intolerance
than when whole undiluted milk and sugar
is used, with a caloric value of 30 calories to
the ounce. Once having obtained such a
strength formula, simply give the child an in-
creased quantity of the same strength through-
out the first year. To supply food almost as di-
gestible as breast milk, and of the same cal-
oric value, is as near as one can approach
breast feeding with a formula. In normal
cases all the calories necessary can be sup-
plied from such a formula, as in the case with
breast milk, up to the sixth month, when
other more concentrated foods, such as vege-
tables, cereals and egg-yolk, should be added
to the diet.
Starting infants with their fluid needs and
enough milk to give 1.75% to 2.3% protein,
with additional carbohydrate, this is rapidly
increased, depending on the gain and diges-
tion of the infant, to a formula of 3% fat,
7.5% carbohydrate, and 2.8% protein, which
will be found, if given in sufficient quantity, to
fulfill the child’s protein needs, and all the in-
gredients will be in a balanced relation. For
every 2 34 oz. evaporated milk, 1 teaspoonful
of strained lemon juice is added, and the food
should not be heated above 100°F. when given
to the baby, otherwise there will be undue
curdling.
Very satisfactory results were obtained in
400 children fed evaporated milk acidulated
with lemon juice, and boiled whole milk acidu-
lated with lemon juice. The records from the
Dispensary of the Children’s Hospital of
Philadelphia and from my private cases were
used. On evaporated, unsweetened milk and
lemon juice the average gain was 6.1 oz. per
week or .87 oz. per day, and the average
length of time on the food was 6j4 months.
The average age at which the food was begun
was 8 weeks. On boiled whole milk and lemon
juice the average gain was 6 oz. per week or
.86 oz. per day, for an average duration of
6j4 months. The average age when this
formula was started was 11 weeks.
The above figures show very satisfactory
gains when one considers that the average
start of these cases was not until the second
or third month, and extended over an average
period of 634 months, bringing the feeding
well into the second half of the first year,
when the normal rate of gain diminishes.
Summary
(1) Normal infants can be fed very satis-
factorily on boiled whole milk or unsweetened,
evaporated milk, acidulated with lemon juice.
(2) Evaporated, unsweetened milk is some-
what more satisfactory when acidulated with
lemon juice than other formulas.
(3) Regulate the formula to give the in-
fant’s fluid needs, then the protein requirements
and enough carbohydrate to balance the food,
giving 21 calories to the ounce.
(4) Mixture of 3% fat, 7.5% carbohy-
drate, and 2.8% protein, acidulated with lemon
juice and made up with unsweetened, evapor-
ated milk gives such a formula.
(5) This feeding, giving 21 calories to the
ounce, as breast milk, shows in a review of
400 cases very satisfactory results, and is pre-
ferred to a stronger formula of higher
calories.
Discussion
Dr. F. I. Krauss (Chatham): I am very much
interested in Dr. Nicholson’s paper. When Dr. Mar-
riott first published his results on lactic acid milk
I was very partial to the use of it; and I have been
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
217
using practically the same type of lemon juice
milk as Dr. Nicholson has for the past year. My
routine in most cases is to use the certified raw
milk and karo sugar. In the more difficult feeding
cases I use an evaporated milk in the same way
and my results have certainly been as good as
with the lactic acid milk; the mothers have less
difficulty in making it up and I think the children
take it more readily. Children who have a ten-
dency to regurgitate retain the lemon milk better
than the lactic acid milk. I have been disappointed
with the use of lactic acid milk in vomiting babies.
Unless thickened with some flour, they vomit it
quite easily.
I should like to ask Dr. Nicholson why he uses
boiled milk and not certified raw milk in making
the lemon juice formula?
Dr. Charles Rosenberg (Newark) : Dr. Nicholson
did not say anything about the bacterial content
of the milk. To my mind that has always been an
important phase of the question. A large propor-
tion of evaporated milk has a high bacterial con-
tent and it has always seemed to me that the bac-
teria of milk after being destroyed are still able
to produce gastro-intestinal disturbances. It is for
this reason that I am opposed to both evaporated
milk and pasteurized milk.
I would ask Dr. Nidholson what he does about
selecting milk of low bacterial content for use in
infant feeding?
Dr. Percival Nicholson (Closing) : It makes very
little difference whether you use raw or evaporat-
ed, unsweetened milk, if there is thorough boiling
of the raw milk. If milk is boiled 10-12 minutes
it will be much better than when just brought to
a boil. After boiling, the milk should be thor-
oughly cooled before acidulation. If large curds
form beat with a Dover egg beater in order to
break the curd up. In Eweiss milk the Germans
advocated boiling after making the mixture and
then beating until smooth. When first used in the
Children’s Hospital the nurse, instead of beating
it at the end of the process, filtered out the curd
of the milk and gave the whey to the children,
with disastrous results. It is very important to
see that these mixtures are not heated too hot,
when being fed to the infant. If you boil the milk
and cool it before acidulation, you get very much
better results than when raw milk is acidulated
without boiling. I have had no pustular rashes in
any of the infants fed evaporated, unsweetened
milk.
In regard to the bacterial content of evaporated,
unsweetened milk, the milk in sealed cans is steril-
ized at a temperature of 240°, so that there are not
even any spore-bearing organisms left. There is
no danger of any kind of contamination. While it
is true that some of this milk may not have been
100% pure, companies usually get their milk where
they are close to the source of supply and have
very satisfactory means of producing it. I have
not had any trouble with gastro-intestinal dis-
turbances, but in diarrheal cases most of these
children will do well on acidulated evaporated milk.
So far as the bacterial toxins are concerned, I
think there may be some present even when the
milk is sterile, but from a practical standpoint I
have had no bad results whatsoever from them.
DIET IN ECZEMA OF INFANTS*
F. I. Krauss, M.D.,
Chatham, N. J.
My reasons for presenting this paper on
the relationship between diet and the eczema
of infancy are, first, that eczema is one of the
most common and unsatisfactory conditions
we have to treat, causing much embarrassment
both to the doctor and parent, and secondly,,
the relative value of dietetic and local treat-
ment offers opportunities for interesting dis-
cussion. I wish to present the results whicbL
may be obtained by diet.
To estimate the value of any treatment in
a condition which often has abrupt cyclic
variations, and which tends to spontaneous
cure, is difficult and may be erroneous. We are
faced with a problem on which the physician's
reputation is often at stake; how frequent is
the history of patient being taken from one
physician to another, the final result being
accredited to some patented medicine.
Our present knowledge would indicate
that most cases of eczema in infancy are either
of an allergic or anaphylactic nature. Cutan-
eous protein tests prove this in. many cases.
There are a considerable number in which
tests are either temporarily or permanently
negative, but which are proved by clinical
treatment to come under this class. Other cases
are associated with some difficulty in the met-
abolism of fat or carbohydrate, or possibly
mineral salts. A combination of any of these
causes increases the difficulty. Associated with
metabolic disorders is some individual hyper-
sensitiveness of the skin. Eczema cannot, from'
an etiologic view, be considered alone but is
grouped with all the other types of metabolic
imbalance. In this discussion we will assume
this as our background, and consider the re-
sults of our clinical experience from a dietetic
standpoint alone. Those cases of eczema
which are of external origin are excluded ; this
applies especially to seborrhea with which
*(Read at the 164th Annual Meeting of the Medi-
cal Society of New Jersey, Pediatric Section, June
12, 1930.)
218
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
eczema is frequently confused. A few cases
will indicate the scope of this paper.
Case 1. In January 1921, S. T. aged 2
months, weight 9 lb. 5 oz., developed an acute
eczema of the face while on a diet of dryco
and dextrimaltose. He improved on skimmed
milk and dextrimaltose, became worse on the
least addition of cream, became even more irri-
tated on skimmed milk and wheat flour, and
again on malted milk. In April 1921, skin
tests showed a marked sensitiveness to cow’s
milk and egg. Mother was advised to con-
tinue skimmed milk. Goat’s milk was tried
without success. When 7 months old, he
weighed 13 lb. 2 oz., and was covered with
a diffuse erythematous, squamous rash. Milk
was discontinued, and a soup mixture made
of dextrimaltose, farina, granum and dried
peas, which contain 25% by weight of pro-
tein, in conjunction with cod-liver oil and or-
ange juice, was fed according to caloric re-
quirements Fresh vegetables were also given.
In 4 days the body was practically clear, and
in 2 weeks the entire eczema had almost dis-
appeared, except for a little dryness of the
face and scalp. This disappeared after 1
month. One month later 1 oz. of milk was
given and the eczema broke out again, but dis-
appeared when milk was withdrawal. Until
over 2 years of age eczema would appear
whenever milk was given.
Case 2. Poppere, Doris A., born August 13,
1929, weight 6 lb. 10 oz., was nursed 1 month
and then put on a milk and dextrimaltose mix-
ture. Began to have colic, and entire body be-
came covered with a fine papular rash. Father
had eczema until 2 years old ; 1 older child
had eczema of face until 1 year of age, and
vomits any egg preparation.
Oct. 9, 1929. Aged 2 months. Wt. 9 lb. 9 oz.
Acute generalized eczema of entire body. Diet :
DTyco and barley.
Nov. 8, 1929. Aged 3 months. Eczema
worse. Given soy bean flour, olive oil, and
barley.
Feb. 28, 1930. Not improved. Wt. 14 lb. 5
oz. Skimmed milk and barley cooked 6 hr.
March 14, 1930. Aged 7 months. Very
much worse. Soy bean flour, butter, vege-
tables, cod-liver oil.
March 22, 1930. Eczema gone except on
face and shoulders.
April 9, 1930. Slight return of eczema.
May 10, 1930. Aged 9 months. Wt. 15 lb.
6 oz. ; 2 teeth; few areas of induration on
arms and legs; no itching.
Skin Tests:
Egg Yolk + + + +
O at meal — 0
Casein -j-
Barley -f- -J-
Milk +
Wheat + + + +
Diet : Soy bean flour, dextrimaltose, rice,
dried-pea mush, vegetables, orange juice and
cod-liver oil.
Allergic eczema cured by omitting causative
proteins.
Case 3. Audrey Grampp, born Sept. 12,
1929, weight 7J4 lb. Nursing.
Oct. 19, 1929. Aged 5 weeks. Wt. 9 lb. 7
oz. Rash on head, face, hands since 3 weeks
of age. Father has had eczema since child-
hood. Mother told to omit eggs, milk, wheat,
potato from diet. Locally, bran baths, cold
cream, and 2% resorcin on scalp.
Dec. 28, 1929. Wt. 12 lb. 10 oz. Eczema
extensive over whole body and face.
Feb. 14, 1930. Wt. 14 lb. 2 oz. No improve-
ment. Nursing discontinued. Mead Johnson’s
soy bean, barley, and olive oil (Sobee) started,
together with orange juice, vegetable pulp and
oatmeal.
March 4, 1930. Wt. 15 lb. 2 oz. Moist
eczema of face and body worse. Began skim-
med milk and barley cooked 6 hr.
March 7. 1930. Eczema worst. Omitted
barley and began rice.
March 21, 1930. Improved. Wt. 15 lb. 3
oz. Vegetables, cod-liver oil, olive oil and
tomato juice started again.
Skin tests on abdomen: Milk -f- -f- ; Oat-
meal -J- ; Wheat -f- ; Lamb -j- ; Barley — | — |- ;
Egg + -J- ; Egg Yolk 0.
April 2. 1930. Wt. 16 lb. 1 oz. ; body clear;
slight scaling and itching of face April 25,
1930. Egg yolk added to formula.
May 20, 1930. Aged 8 months. Wt. 17 lb. 2
oz. ; skin clear; slight itching. Diet: Whole
milk cooked 6 hr.
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
219
Allergic eczema cured by prolonged boiling
of skimmed milk.
None of these cases developed rickets,
scurvy or any deficiency disease ; they were
underweight but full of energy; they teethed
normally.
It is most important to obtain the parent’s
cooperation. They must be made to under-
stand that eczema is both a state of abnormal
sensitivity of the skin, and of abnormal reac-
tions to food, with which the infant was prob-
ably born ; that it may be most obstinate to
cure or to relieve ; that it may persist through-
out the first or even the second year of life;
that it is not permanently disfiguring; it may
not be detrimental to the health ; tends to
spontaneous cure after 2 years ; and that, most
important of all, we must consider primarily
the general development of the infant, and
whatever we do in the modification of diet
must have this as a basis. Unless we explain
these factors we will soon lose our patient to
another physician.
Among nurslings a large percentage of
eczemas are due to allergy to foreign proteins
to which the mother herself is not sensitive.
Dr. O’Keefe states that when the offending
protein is removed from the mother’s diet,
cure or improvement in more than half the
cases follows. I recently saw a child, 5 weeks
old, where omitting wheat from the mother’s
diet cleared up the condition immediately, with
a recurrence when wheat was added again.
If the nursling is sensitive to cow’s milk or
egg, removing these from the mother’s diet
will often help. The supply of the mother’s
milk can be kept up by other foods. It is
wise to omit from the mother’s diet any food
to which the infant gives a positive reaction.
However, as we do not always get a positive
reaction to the offending protein we must con-
sider our clinical judgment as of equal value
with skin tests. Eczema may be a general
protein sensitization or a hypersensitivity to
fat or carbohydrate metabolism.
Case 4. Typical of eczema in a nursling.
Born Nov. 4, 1929, weighing 9 lb. 10 oz. Seen
first on Jan. 21, 1930, aged 11 weeks, wt. 14
lb. 11 oz. Nursing 8 times in 24 hours; bow-
els constipated ; regurgitates ; past 6 weeks
itching rash on face, head, and back. The
mother is stout ; had an acute eczema before
the baby was born. The baby has an acute
erythematous eczema of the face and body
with crusts in the scalp and on the cheeks.
Tests: Mother, cow’s milk -j- + ; oatmeal
-j- -j-. Baby, human milk 0; cow’s milk 0.
Treament: Mother’s diet to consist of
fruits, vegetables, soups and nuts and to take
soda bicarbonate 51, b. i. d. Local treatment
for the infant — calomine lotion with cold
cream. The eczema cleared up in 1 month.
This infant was probably sensitive to over-
feeding with too rich milk. Many nurslings
with eczema are overfed; they are usually
overweight. In such cases lengthening of in-
tervals between feedings, reducing length of
nursing period, and supplying water, plain or
alkaline, is of benefit. Many nursing mothers
drink too much milk or eat too much carbohy-
drate ; a more liberal use of fruits and vege-
tables, with less milk and no food between
meals, should be tried. Skin tests on the
mother are of no practical value. If these
various measures fail, then one can consider
artificial feeding.
Nursing infants sometimes do better when
nursing is discontinued. Whether or not to
continue nursing is a very difficult question.
If the infant is near the age when bottle feed-
ing would have to be started soon, it is ra-
tional to begin cautiously. If the eczema is
aggravated, one can still fall back on breast
feeding a little longer. I think the very young
infant should be breast-fed, with the mother’s
diet adjusted, and with the use of local sooth-
ing applications. The limitations in the diet of
a very young infant are too great to permit
of much experimentation without danger to
the vitality.
In the bottle fed baby a detailed history is
very important. We usually find that the
eczema started a short time after cow’s milk
was begun. Then arises the question whether
the fat, carbohydrate or protein is at fault,
or whether all these may play some part;
usually it is the protein. Case No. 1 illustrated
this. The eczema appeared on a diet of dryco
and dextrimaltose ; it improved on skimmed
milk and maltose, showing an idiosyncrasy to-
220
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
ward fat. The skin tests showed a marked re-
action to cow’s milk protein. Thus, in this case,
these 2 factors had to be considered. The
mother was most anxious to get rid of the
eczema; her entire attention was focused on
it. One of our best pediatricians advised her
to continue skimmed milk with the dictum
that the protein of cow’s milk was absolutely
essential to the baby’s growth. With consider-
able hesitation I took the child off milk and
made up an artificial milk, obtaining protein
from dried peas. The results were immediate.
This was my first experience in feeding a
young infant permanently without milk.
For these cases of milk protein sensitiza-
tion, an artificial milk using soy bean flour as
source of the amino-acid protein, has been re-
ported recently. Soy bean is rich in amino-
acid. Drs. Hill and Stuart, of Boston, have
reported gratifying results in a series of cases.
Soy bean contains 40% protein and 20% fat,
and according to Osborne and Mendel con-
tains an adequate supply of both fat soluble
A and water soluble B vitamins. Dr. Schloss
reported the use of soy bean protein in 1920;
6 cases of milk protein eczema put on a diet of
lactose, mineral salts, washed butter and soy
bean protein, and eczema practically disap-
peared in 3 days ; the mixture caused vomiting
and diarrhea in 4 cases.
Since soy bean flour has been put up in
combination with olive oil and barley flour for
commercial distribution, I have used it in 6
cases ; 3 were cured, 2 were improved, and 1
unimproved. A few cases in which I wished
to use it either refused the food in sufficient
amount to maintain nutrition or developed
diarrhea. Three cases which made partial im-
provement gave a reaction to barley, and did
not clear up until the pure soy bean flour was
used. I am indebted to the Mead Johnson
Company for a supply of pure soy bean flour
for these cases. The preparation now put up
by them should be adequate in most cases of
milk allergy, as it is only the very exceptional
case which will be sensitive to both milk and
barley. If further clinical experience shows
that infants will thrive on this soy bean diet,
it will furnish a valuable addition in our treat-
ment of milk allergy.
The importance of keeping up nutrition
must be strongly emphasized. If these in-
fants lose weight they lose vitality very
quickly. They are particularly sensitive to
skin infections, especially of the face with
secondary cervical adenitis, and to catarrhal in-
fections of the nasopharynx and bronchial
tract. They lapse very quickly into a danger-
ous state of infection or malnutrition.
As omitting milk from the infant’s diet is
an uncertain and possibly dangerous proced-
ure, methods of modifying milk protein must
be considered. First, a reduction of protein
to the minimum needs, according to age and
weight, should be undertaken. Schloss states
that lactalbumen is the most active protein; in
which case, feeding a high casein milk may
be of some value. Dr. Kerley told me that he
uses it in cases where he is not getting the
results which he desires with the prolonged
boiling of skimmed milk. Several of my pa-
tients are taking casein satisfactorily. Protein
can be modified by either drying the milk or
by prolonged boiling, especially with a cereal
flour. Complete or partial drying, as in pow-
dered milk and evaporated milk, helps many
cases. Kerley believes in boiling the milk in
some cases 6 hours. He uses skimmed milk
boiled with rice for from 3 to 6 hours. The
prolonged heat changes the protein. Rice is
used in preference to barley because fewer in-
fants are sensitive to rice than to any other
grain. Kerley stresses the importance of pro-
longed heating. We frequently hear the his-
tory that the milk was boiled a few minutes,
sometimes for an hour, without results. There
are a number of mild cases that are cured this
way, just as many are cured by the heat
changes produced by drying milk ; severe cases,
however, need prolonged boiling of the milk.
There are certainly many cases of milk allergy
which do well when the protein is modified
by one of these methods. I have not found
acidified milk of any particular value in
eczema unless there is an associated entero-
colitis ; when improvement occurs in these
cases it is doubtful if the eczema is a true al-
lergy.
Protein eczemas seem to be cyclic. It is re-
markable how an acute condition will subside
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
221
and hardly be noticeable in 24 hours, then re-
appear suddenly without any change in the
diet whatever. The skin tests also show this
tendency, so that a negative test does not
necessarily rule out a food. A test negative
at one time may be positive at another. On
account cf this, many cases should be diag-
nosed by the history, and treated accordingly
if tests cannot be made. I, personally, rely
more on the history than I do on the skin re-
actions, for we know that these are only posi-
tive in 60-80% of cases. Other cases of al-
lergy such as those due to egg, wheat, potato,
orange juice, beef, lamb, are easily amenable
to the omission of these foods from the diet.
Next to milk protein, egg albumen and wheat
are the most common proteins causing eczema.
Eczema in infants in the second year and in
young children respond very satisfactorily to
the omissions of the causative proteins. The
eczemas are usually small areas of a chronic
type, which are not subject to the severe itching
and infection which complicate with babies
under one year of age. The opportunities to
vary the diet are much greater without danger
of under-nutrition or vitamin deficiency.
Overfeeding with fats or carbohydrates:
Some infants cannot tolerate any milk fat what-
ever, and must be given a centrifuged skimmed
milk, and their fats supplied either by olive
oil or cod-liver oil. White found in the stools
an excess of fats in the moist type of eczema,
and an excess of starches in the dry type. I
find it difficult to form any opinion from the
appearance of the eczema whether the carbo-
hydrate or the fat is at fault ; clinically, I
have found the fat usually the important fac-
tor, and next in importance to milk proteins.
If the skin tests are negative or cannot be
done, and an analysis of the history and diet
give the impression that the infant is not
metabolizing fat, it is a simple matter to try
skimmed milk for a few weeks. Boiling the
milk, as mentioned before, will also help.
Naturally, reduction in either fat or carbo-
hydrate means an increase in the other, if suf-
ficient calories are to be given. These chil-
dren have what Czerny calls the exudative
diathesis. The balance in diet is very sensi-
tive. When feeding carbohydrates, it is
usually wise to use the cereal flours cooked a
long time rather than any of the pure sugars.
Rice is probably the safest of all as there are
fewer infants sensitive to rice than to wheat,
oatmeal, or barley.
As soon as possible, cereals, vegetables and
fruits should be added to help supply caloric
requirements. The more varied the diet from
day to day, the less likely is the eczema to
become severe. Here, also, prolonged cooking
is of assistance. So many of these eczema
babies have colic that careful preparation of
the food is essential, the colic being another
evidence of sensitivity.
Malnutrition is a common cause of eczema;
mostly of the seborrheic type. The mild cases
are simple seborrheas of the scalp, and the
more severe are dry, indurated, scaly, or fis-
sured areas, especially on the outer aspects of
the arms and legs. These cases respond quickly
to general improvement in the infant’s nutri-
tion ; the easiest cases to cure by diet. They
must be differentiated from myxedema, with
which they are sometimes confused, as thy-
roid medication is not indicated.
I have not found constipation an etiologic
factor in my cases ; the condition of the skin
does not seem to depend upon it. Constipa-
tion is often present, but not more frequently
than in the large number of bottle-fed infants.
One does notice an improvement sometimes
after an attack of diarrhea, which might indi-
cate some relation between eczema and consti-
pation ; but I have not seen that giving laxa-
tives or laxative foods has helped. This idea is
at variance with the opinions of others who lay
stress on the necessity of 2 or more free move-
ments daily.
The local treatment of eczemas of dietetic
origin is directed to : first, protection from
trauma ; second, cure of infection ; and third,
relief of the burning and itching. Those which
respond most rapidly to diet are the dry type
with very little itching. If the infant is al-
lowed to scratch an infected area, this alone
will keep up the dermatitis indefinitely. The
burning sensation is the last symptom to dis-
appear and the skin must be protected during
this length of time. A few minutes rubbing
will undo the work of days. Most of our local
222
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
treatment fails because it is not persisted in
thoroughly. When once clear, the skin will
remain well or improved so long as the diet
is carefully adjusted and the hypersensitive
skin protected. In the majority of cases the
local treatment is not as important as the
dietetic treatment ; the difference between al-
lergic eczema and dermatitis of other origins
being that an allergic eczema cannot be cured
or kept cured unless the allergic factor is
modified or removed.
Conclusion
In considering diet in infantile eczema, the
causes to be considered are milk or other
protein allergy, overfeeding both in the nurs-
ling and bottle-fed, fat or carbohydrate im-
balance in the diet of the individual, and mal-
nutrition.
The most difficult cases are those due to
milk protein allerg)'. There is no universal
substitute for milk. Some infants can be made
to thrive without milk, but the danger of un-
der-nutrition is too imminent to permit this
therapy except in carefully supervised cases.
The protein of the soy bean is rich in amino-
acid, and apparently can replace the protein of
milk in early infancy. Some infants who can
assimilate this protein, gain in weight and
energy; others suffer in vitality.
Mild cases of milk protein allergy are helped
by prolonged boiling or drying the milk. The
milk must be boiled from 3 to 6 hours; suc-
cess or failure often depends on this point.
This is the most conservative and safest way
to treat milk protein cases. It is wise to be
satisfied with the improvement obtained when
an absolute cure does not occur.
Eczemas due to fat or carbohydrate imbal-
ance respond satisfactorily to diet modifica-
tion.
Eczemas due to malnutrition respond
quickly to the general improvement in tissue
turgor.
Diet alone will clear up many cases if
trauma is prevented and infection removed.
Allergic cases will relapse if the diet is neg-
lected
Most allergic eczemas disappear spontan-
eously by the end of the second year.
The welfare of the infant must not be
sacrificed for the local condition; and any
modified diet must be balanced sufficiently to-
maintain health and promote growth.
Discussion
Dr. Arthur Stern (Elizabeth): Dr. Krauss was
kind enough to let me have an advance copy of
his paper on a subject which has been of extreme
interest to all of us and as it deals mostly with
the treatment, I must confess that his part has
been to me in my practice full of pleasure and
disappointment. Pleasure, when by removal of the
child from the breast to artificial food, the eczema
disappeared, never to return; disappointment, if
after all cutaneous tests and changes of the food
according to reactions obtained, the results are
negative.
Dr. Krauss states that our present knowledge
would indicate that most cases of eczema are either
of an allergic or anaphylactic nature. I thought
once that I was convinced of this but there are
other factors which play an important part in the
appearance and disappearance of the eczematous
eruptions. .Just let me mention one case to show
how hard it is to understand the underlying con-
dition.
Baby W., 3 years old, had slight eczema when
breast-fed. The child was then tested and reacted
positive on peas, white potatoes, wheat, tomatoes;
and negative on cow’s milk. It was then put on
many different milk formulas, with the result that
the eczema became much worse. While potatoes,
wheat and tomatoes did not increase its severity,
peas caused an enormous, edematous swelling of
the lips but did not affect the eczematous areas.
At random let me recite from Finkelstein the
following observations in his text-book on Dis-
eases of the Nursling, page 797: “I removed a large
number of eczema children into a room where all
the windows were covered' with red paper, so that
the spectral colors on the other side of green
could not penetrate, and left them there for sev-
eral weeks. Mild cases were cured within a few
days. After they had been put back into the ward,
the eczema reappeared. Severe cases were not in-
fluenced whatsoever.”
Furthermore, if the eczema would be due ex-
clusively to allergic or anaphylactic conditions,
there would be no reason why we see (and most all
authors differentiate between these fioints), the 2
types, namely, the facial form, mostly in older
nurslings, and the universal form, the eczema'
simplex et intertriginosum, in older children.
Another observation made by Samberger is in-
teresting. He found in the eczematous crusts a
ferment similar to trypsin and as the reaction of
the crusts and their serum was alkaline, he tried
an acid salve consisting of acetic acid and lano-
lin, which is said to have acted remarkably well
in his cases. KJingmueller then introduced the
acid tar baths into the treatment of general eczema
and in one of the large hospitals of Europe they
have been in use for several years. The patients
are bathed for 10 minutes and then dried and
powdered. The results are reported to be very
good.
If we assume that eczema, asthma, urticaria and
hay-fever belong to the allergic group of diseases,
we still cannot understand why in some persons
their occupation produces localized eczematous
conditions as we see them in plasterers, bakers,
gasoline workers, furriers, and also eczema in dia-
betics, gouty people, and so on. I have seen a boy
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
223
who had a lip eczema which had been treated by
the foremost dermatologists and it was very ob-
stinate. The other part of his body was free.
Changes in diet had no influence whatsoever. 1
have also seen a diabetic child after a few years of
insulin treatment develop a dry eczema. The rash
disappearance of an eczema during an acute in-
fection or even during the weeks of the healing
of a fractured leg, gives us food for thought.
So, after all, there must be a peculiar condition
of the skin itself which, as the dermatologist Ber-
ing, in a recent paper on “Poor Results in the
Treatment of Eczema” emphasizes, is the cause
of eczema. In order to develop an eczema, he
says, 2 things are necessary, the eczematous irri-
tation and the peculiar condition of the skin. He
mentions the following experiment: Small pieces
of gauze soaked in different test solutions are put
on healthy skin, then covered with oilskin and ad-
hesive plaster; after 1 or 2 days the degree of
irritation is controlled. Several persons who had
eczema showed a very sensitive skin, but in several
others, who never had a skin eruption, the same
degree of irritation was found. These latter may
be potentially eczematous and will get eczema
■when the special irritation will attack the per-
fectly healthy skin.
But with all these newer ideas I have very little
to offer in connection with Dr. Krauss’ paper,
which is excellent and timely, nor with his deal-
ings with eczema which in my private practice are
similar to the treatment described in the paper.
The few thoughts mentioned in this discussion have
come to me during the treatment of some of the
obstinate cases but as the etiologic factor is hard
to define in many other diseases, this also holds
good for the treatment of eczema at the present
time.
Bering says: “The physician who follows the
principle to remove the cause of the disease, if such
is known, and then treats carefully and systematic-
ally wTill have the best results, surely, in the fu-
ture treatment of eczemas in childhood.”
Dr. F. C. Johnson (New Brunswick) : I would
like to ask whether any one has had experience
with cases which have been determined to be
sensitive to arsenic?
ECZEMA IN INFANCY, FROM THE
DERMATOLOGIST’S STANDPOINT*
F. J. McCauley, M.D.,
Newark, N. J.
Eczema, as it occurs in infancy, does not
differ from its manifestations in adult life; i.e.
a dermatitis, of varying intensity of inflam-
mation, appearing as erythematous, vesicular,
papular, or pustular lesions ; or as any com-
bination of these. The most recent conception
of eczema is that it is a hypersensitivity of
the skin to some irritant. Instead of consider-
*(Read at the 164th Annual Meeting of the Medi-
cal Society of New Jersey, Pediatric Section, June
12, 1930.)
ing eczema as a clinical entity it is best to re-
gard it as an inflammatory reaction in which
3 clinical types can be observed.
First, are cases considered under acute der-
matitis, in which the skin is sensitized mainly
to known local causes, and which quickly re-
spond when irritants are removed. Another
group can be regarded as allergic in character.
In these cases we will generally find some form
of protein, to which the patient is sensitized,
giving rise to repeated attacks throughout the
lifetime of the individual ; this type is com-
monly associated with asthma and hay-fever.
The third group, and by far the most common
in early life, is seborrheic dermatitis. Here we
have a classic progression of clinical signs, by
which we can place it definitely as an entity,
varying in intensity according to the peculiar
predisposition of the individual. We have
therefore in eczema a dermatitis where many
causative factors will have to be considered
but by grouping, as above outlined, we can
greatly simplify our efforts. In group 1, local
causes can easily be established in most cases ;
group 2 may offer considerable difficulty, but
we are getting into a better position, in our
methods of isolating causative allergic factors ;
group 3 cases have a well established clinical
entity, and in looking at the subject from the
standpoint of early infancy, we find this type
so frequently that from a therapeutic view-
point it occupies the most important position,
constituting by far the majority of our cases.
In the etiology of eczema today, we are mostly
concerned with conditions that lead to skin
sensitivity.
Under local or exciting causes, we have to
consider all forms of irritation applied to the
skin of a susceptible individual. This in-
cludes mechanical factors, such as friction of
clothing, scratching, simple pruritus and para-
sites ; thermal agencies, such as cold, heat,
therapeutic lamps, acting rays of the sun and
therapeutic lights ; chemical irritants like soap,
saliva, nasal discharge, urine and feces. While
there is a diversity of opinion regarding mi-
croorganisms, we feel they play an important
part in the causation of this disease and are
entirely responsible for the group 3 cases. In
this type, experiments have proved the dis-
224
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEi’
March, 1931
ease has been reproduced by inoculation of
pure culture of the spore of Malassez, and
Elliott and Merrill produced the disease with
a diplococcus and a bacillus, and recovered and
cultivated the microorganisms. Further, Bock-
hart has advanced the theory that the Staphy-
lococcus albus may become active in the fol-
licles, producing toxins, and by diffusion of
these products in the epidermis cause eczema.
Under internal or predisposing causes, nu-
tritional and digestive disturbances are mainly
responsible. A majority of patients in this
group have been overfed, while others will
show excessive fats or starch in the stools. In
prolonged cases, a sensitivity peculiar to the
individual constitutes the important factor, and
this may be hereditary or acquired, transitory
or permanent. In the hereditary type we
usually find a 'congenital functional defect.
The skin of these individuals is abnormally
dry and represents a mild type of ichthyosis,
to which the term xerodermia has been ap-
plied. Cases are presented, however, in which
this feature is hardly evident, and only care-
ful inspection will reveal the abnormal dry-
ness of the skin. These people are prone to
develop eczema during the winter months,
when the skin function of stabilizing tempera-
ture is at its maximum. In the acquired type
the skin may become sensitized by a single ap-
plication, or by repeated exposure to an irri-
tant, and continue to develop eczema from
very mild and dissimilar irritants. Other in-
ternal causative factors are various conditions
responsible for an elevation of temperature,
such as intestinal disturbances, the various
toxemias and dentition.
In treatment, our first endeavor is proper
feeding of the patient, and this is referred to
the pediatrician or family physician with gen-
eral instructions : if overfed, to modify the
amount of intake, and if a nursing baby, the
suggestion is made to reduce the amount of
intake by giving a small quantity of cereal
water before each nursing. In cases that are
normal in weight, an examination of the feces
is advised and, if unsuccessful in determining
an abnormal digestion, further tests for pro-
tein reactions should be tried. If milk is found
responsible, an attempt at desensitization is
advised by giving milk in small amounts and
gradually increasing the quantity as the pa-
tient’s tolerance is increased. This procedure
has been found successful in many cases. After
the nursing period we are usually in a better
therapeutic position, and in cases that are very
resistant we can substitute a diet free from
allergic articles, or a diet in which they can
be brought down to a point of tolerance.
Among the foods most frequently at fault in
producing a dermatitis we would place or-
anges, eggs, butter-fat, milk and cane sugar.
Next, the character of the skin must be
taken into consideration: if abnormally dry,
infractions as to a diet rich in fats, or cod-
liver oil is advised during the winter months;
and the patient protected against exposure to
severe winds or drafts. Cases of this type are
very frequently misjudged, being treated with
all kinds of stimulating ointments which in-
crease the irritation and add to discomforture
of the patient, while the use of mild soothing
remedies will succeed in affording relief.
We now come to the most common causa-
tive factor, namely, seborrheic dermatitis,
which is a parasitic infection. While errors of
diet and skin hypersensitivity play an import-
ant part in seborrheic dermatitis, in most cases
we succeed by local treatment exclusively. The
clinical symptoms of this condition are present
in the majority of cases of so-called infantile
eczema, and as it may continue throughout
the life of the individual, its recognition in in-
fancy becomes an important feature, as proper
treatment at such time frequently results in its
termination.
In the local treatment of infantile eczema
we are dealing with an acute dermatitis, and
although remissions in intensity are the rule,
the end-results of infiltration and keratotic de-
velopment seen in adults seldom show in
early life. Stimulating remedies such as tar,
sulphur, mercury and resorcin, unless used
with extreme caution, will tend to defeat our
purpose by increasing the inflammation rather
than reducing it. Only in cases that have pro-
gressed to a low grade inflammation, the lesions
being of a continuous character and consisting
of a few circumscribed patches, should these
remedies ever be considered. Local treatment
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
225
can be summed up under 2 headings., namely,
antisepsis and soothing protective applications.
In the management of a case we pi'oceed
about as follows: the child is to be guarded
against undue exposure; cotton or silk is sub-
stituted for woolens, which increase pruritus ;
linens should be soaked in an alkaline solution
before washing. The important question of
cleanliness now presents itself. Soap is an
irritant to an inflamed skin, but washing with-
out soap is our basic therapeutic forte. A
solution of borax is used and, regardless of
the extent of the eruption, a borax bath (one
tablespoonful to a gallon of water) is given.
In very acute cases intervals between baths are
extended to 3 or 4 days, depending upon the
amount of reaction induced ; gradually the in-
tervals are shortened as the inflammation sub-
sides, until a daily bath can be given. For in-
flamed areas, including the scalp, washing
morning and night with borax solution is ad-
vised, using absorbent cotton for sponging; or,
in very acute cases an oatmeal or bran sponge
may be found helpful — gauze bags of cooked
oatmeal or bran. These sponges can also be
used in tub bathing and will be useful as a
soothing agent. Recently, witch-hazel has
been used and will be found a valuable addi-
tion, particularly in washing the scalp, or on
other areas preceding each application of
medication. It is especially indicated if the
borax solution be found irritating. Any oint-
ment of a non-stimulating character is then
applied. A base of lanolin or petrolatum, add-
ing oxide of zinc as a mild astringent, and
salicylic acid to prevent decomposition, will
make a good combination and fulfill all re-
quirements. This is to be applied sparingly,
using only an amount sufficient to cover the
skin as lightly as possible, and then dusting
over the surface a drying powder of either
starch or talc. It is important that only a
small amount of ointment be used at each
dressing, as the object to be obtained is to
cover the affected areas with a soft, pliable
protective covering, and an excess of grease
will tend to cake and form lumpy masses which
add to the discomfort. Applications morning
and night are usually sufficient, keeping the
parts covered in areas of moderate inflamma-
tion, but in locations in which exudation is
present, especially on the cheeks, more fre-
quent applications will be required. On the
abdomen and back, the eruption is usually less
aiute and the patient can be made comfortable
with a less oily preparation. An alkaline wash
followed by application of ung. aqua rosae,
with gentle rubbing until the skin feels only
slightly oily, and then covered with a dusting
powder, will make an easy and comfortable
dressing, and in most cases require only morn-
ing and night applications.
The scalp will require special attention ; in
cases with heavy, oily, adherent crusting,
washing with any of the solutions mentioned
and covering with gauze spread thickly with
petrolatum, 2 or 3 times a day, will be found
effective. In a few days the crusting will
cease to develop, and a lotion can then be
added as it is less objectionable than a greasy
ointment. A solution of salicylic acid, beta-
naphthol, or resorcin may be used, adding a
small amount of castor oil.
In cases that have progressed beyond the
stage of acute inflammation, a half-dram of
beta-naphthol may be substituted for the re-
sorcin as it is slightly stimulating in character
and a good bactericidal remedy. In using
beta-naphthol care should be taken to limit ap-
plication to the scalp, as it causes an uncom-
fortable smarting or burning sensation on other
locations. These applications should be con-
tinued over an indefinite period, either daily
or at intervals sufficient to keep the scalp clean
and clear of scales. This step is important
and will prevent recurrences in cases of the
seborrheic type.
The plan as outlined above, while not al-
ways effective in controlling the intense pruri-
tus accompanying acute exacerbations of the
disease, tends to greatly modify the discom-
fort, and in the quiescent period supplies a
protective covering for the epidermis, thus
aiding in the process of repair, in the repro-
duction of the horn cell or protective layer of
the skin, which is all one can aim to do from
indications in local treatment.
The subject of infantile eczema is a most
troublesome one both from the standpoint of
the patient and the family, but with persistence
226
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
and cooperation in carrying out the plan of
treatment outlined, we can always look for a
good result. Cases due to simple errors of
metabolism usually respond quite readily. The
most difficult to control will be the patient in
whom we find a protein sensitivity, but by
careful and painstaking efforts at desensitiza-
tion to the specific proteins we can often suc-
ceed in bringing even these cases to a favor-
able issue.
Discussion
Dr. H. J. F. Wallhauser (Newark) : I have en-
joyed listening to the various papers presented
and wish to extend my thanks and voice my ap-
preciation of the progress that has been made
in infant feeding and the resulting improvement
that has been developed in the treatment of mal-
nutrition in infants.
Drs. Nicholson, Krauss and Rosenberg have cov-
ered the subject from the standpoint of diet very
well, and Dr. McCauley has brought out the main
features from a dermatologic viewpoint. In a
brief way I would like to stress a few points re-
garding the various phases described.
Eczema of infancy constitutes one of the most
trying maladies with which we have to contend;
the intense pruritus which accompanies this in-
flammation, causing the patient to scratch until
raw bleeding surfaces result, is evidence of the ex-
tremely annoying character of the condition, and
the effect on the family is likewise a serious fea-
ture, since the discomfort of the patient is ever
before them. We are, therefore, many times placed
in a difficult position in finding remedies for relief
or palliation.
In my early days, eczema was regarded as an
entity and we were taught to treat the acute stage
with soothing remedies and the chronic stage with
stimulating remedies and, so far as adult cases
are concerned, this plan still holds good thera-
peutically in regard to local measures, but in in-
fants we are dealing only with the acute type of
inflammation, and even though cases occur that
show a low grade inflammation, with infiltration
and thickening in patches, they seldom if ever re-
quire stimulating remedies. Eczema, as Dr. Mc-
Cauley has suggested, is being considered today
as an inflammatory reaction which may be due
to some local irritant or internal constitutional
cause leading to the development of skin sensi-
tivity. This does not differ greatly from Bate-
man’s description of nearly 200 years ago, in
which he described eczema as an inflammation of
the skin due to external and internal causes in an
individual who was susceptible. The term skin
sensitivity, however, more briefly defines the con-
dition. We have succeeded in isolating many of
the conditions that are responsible, both of internal
and external origin, and have a better understand-
ing of the principles involved, yet we are a long
way from the final analysis of this protein disease
in which the skin manifestations can only be con-
sidered as a symptom in the complex forces con-
cerned in its production. Considered as a skin
sensitivity, which may be permanent or transitory,
we are in a position to group our cases under
defiinite conditions leading to therapeutic measures
in management and treatment; i.e., under perm-
anent sensitivity we find congenital skin de-
fects; in the transitory class, digestive disturb-
ances; while under local causes all factors of an
irritating nature are included.
In the local causes, Dr. McCauley laid great
stress on parasitic infection and described the
definite clinical manifestations of dermatitis
seborrheicum as the most common, in which var-
ious parasites, although not definite, are held re-
sponsible. Isolating the various clinical manifes-
tations of this disease under a specific cause has
added greatly to our success therapeutically in
adopting aseptic measures. In the application of
treatment all the conditions that may be respon-
sible, both internal and external, are taken into
consideration, including particularly the nature or
degree of the inflammation. A slowly progressive,
mild, scaly, erythematous eruption, without in-
tense reaction, can be treated by local measures
alone, while cases that show intensive inflamma-
tory exacerbations will require careful study re-
garding internal contributory causes. In the pro-
longed persistent type, protein sensitivity is most
generally found responsible and offers the great-
est difficulty in control. These cases will have to
be tested for specific allergic articles and treated
by methods of desensitization. Of all the predis-
posing factors, however, overfeeding is probably
the most common, and is generally apparent by
the robust fat, healthy appearance of the majority
of cases of infantile eczema that come under ob-
servation.
Dr. McCauley mentioned orange juice as a pos-
sible allergic article. I would like to add that this
is the most common cause leading to skin sensi-
tivity, and should receive more careful considera-
tion in advising parents as they are very apt to
encourage immoderate quantities of orange juice
to the exclusion of other fruits of equal value. In
local treatment, we regard the condition as an
acute or subacute inflammation and treat it ac-
cordingly with soothing and protective measures,
including cleanliness. Regarding the latter, we
were taught, and followed for many years, the
teaching that water was harmful and should never
be used in eczema, and it took many years to wear
out this erroneous impression, for we had to over-
come the fact that washing actually aggravated the
condition. Persuasive measures finally succeeded
in proving the temporary aspect of this excitant
and that cleanliness was an important aid in treat-
ment.
Experimenting with various liquids that might
be used for this purpose, in the removal of scales
and crusts, the various fixed oils were employed,
including olive oil, sweet almond oil, cocoanut oil,
oil of sessame and milk, all of which seemed to be
beneficial for a time, but in the end would be found
irritating and in many cases responsible for re-
lapses. This was especially so regarding milk,
which was responsible for recurrence in cases in
which protein sensitivity was present. All the
above applications were found unsuited and grad-
ually gave way to alkaline lotions, which were
found less irritating and often tended to relieve
the intense pruritus. The method of bathing has
been well defined by Dr. McCauley and I have
mentioned it only to show its importance and the
obstacles in its establishment as a routine measure.
Particular attention was called to the treatment
of the scalp in the prevention of relapses, and I
would like to add that all cases showing a predis-
position to development of decided scaling in the
scalp should continue the use of antiseptic lotions
and cleanliness as a toilet measure indefinitely.
Eczema or skin sensitivity leading to dermatitis,
as it is now being regarded, constitutes a problem
that appeals to all of us, in working out the var-
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
227
ious responsible causative factors, and in childhood
we are in a better position than later in life in
determining- many of the predisposing causes,
more especially those relating to congenital ab-
normalities and digestive disturbances, and our
success in treatment will depend upon giving each
case careful study, especially regarding the con-
stitutional contributory causes, in the development
of skin sensitivity.
Dr. Elmer G. Wherry (Newark) : I would like to
congratulate Drs. Krauss and McCauley on then-
courage in coming here and talking about a subject
that is so hard to deal with. I can add nothing
whatever to what Dr. Wallhauser has said except
a few practical suggestions which have possibly
already been brought out but perhaps have not
been sufficiently stressed.
Dr. Wallhauser told me 25-30 years ago that it
was very easy to cure such cases provided you
did not have to save the child, and I think that is
still true. Where we get a case of eczema that
has not an intolerance to milk, the patient can be
made very much better by changing to skimmed
milk. As the baby loses weight the eczema will
disappear. That may be very gratifying for a
short time but if it develops a bronchial pneu-
monia and dies the treatment is of no avail, and
that may easily happen.
Regarding the subject of tolerance, I believe that
a child can be kept for a few days on skimmed
milk and then the milk can gradually be made
stronger, for I believe that the child has the abil-
ity to establish a tolerance to almost any kind of
food even though that food may be toxic to him
at the start. If you consider that when we were
small boys we sneaked behind our father’s barn
and got sick on a cigar, and yet all those of us
who had the courage to persist are now able to
smoke several cigars a day; when you consider
that nicotin' is a poison and that we were able
to establish a tolerance for it; it is not so strange
that we can establish a tolerance for orange juice,
milk and eggs, if we go at it patiently and per-
sistently.
One most important thing that has been left out
entirely in this discussion, as a therapeutic meas-
ure, is insisting on the child drinking plenty of
water. I think that is of great importance. Dr.
Krauss did speak about giving fruits and vege-
tables to the mother in order to reduce the fat,
but that simply reduces the fat in the milk, as
meat is the substance of the mother’s diet that
will produce fat in the milk. That is simply an-
other way of giving the child a starvation diet.
Dr. McCauley, speaking of dermatitis, really gave
us the hint of how to be successful in most of our
cases, and that is simply a matter of curing the
scalp and you cure the disease.
Some of these cases can be cured only when we ’
have the active cooperation of some intelligent
caretaker in place of the mother. The mother
will not always do what a trained nurse will do.
We have frequently taken cases to the Babies'
Hospital in Newark, and we cure them by what
the nurses call crucifying them. We do not dare
do that in the home. By crucifixion we simply
mean pinning the child’s sleeve to the mattress
so that it cannot scratch, and that is done con-
stantly except when the children are being held
by the nurse. I had a case a short time ago, a
21 months’ old child, well nourished but unable
to sit alone; had no teeth; had many of the signs
of rickets, and with a severe dermatitis which was
vastly worse than any of the pictures shown by
Dr. McCauley. The child had been treated by a
dermatologist in Buffalo for several months, with
no results. The family then moved to Arlington
and the baby was treated by other doctors, with
no results. I was consulted and I spent an hour
telling the mother, who was a very intelligent
woman, what to do. I decided that she would fol-
low my instructions and expected some improve-
ment. There was no improvement for Sy2 months.
I then took the child to the hospital and within
3 days, on skimmed milk, the child lost approxi-
mately 3 lb. and became so weak that it could
hardly cry aloud. His condition was so bad that I
feared I would lose him. However, his eczema im-
proved on the same treatment he had been having
in his own home. I then put him on a most lib-
eral diet, excluding orange juice. The child im-
proved wonderfully and within a few weeks was
practically cured. That child’s scalp was shaved.
The improvement of his general dermatitis follow-
ed immediately the curing of his scalp.
A short time after that a similar case was
brought to my office and I absolutely refused to
treat it unless I could have the child in the hos-
pital. The mother was about as stubborn as I
was and asked me to give her a chance to see
what she could do at home. I gave her the same
general advice which had been used so success-
fully in the first case and 6 weeks later the child
was entirely cured.
These cases can be handled much more easily
in a hospital than at home and are ordinarily
cured more rapidly.
Dr. Percival Nicholson (Philadelphia) : There is
a method of treatment that has not been mention-
ed. A great many of these children can be fed
on ordinary types of food if they are given in ad-
dition ultraviolet treatment. If the chronic type
of case is given rather massive doses locally and
then general tonic treatment of ultraviolet lights
you can usually maintain fairly liberal diet with-
out detriment to the child.
In 1909, Dr. Ruhrah, of Baltimore, used soy bean
flour in the treatment of diarrheas. That was
used very extensively in giving high protein long
before “sobee” was brought out.
My experience with goat’s milk has been rather
unsatisfactory. It has very little effect in most
of these cases. There are lots of children that give
no active skin reactions to certain food ingredients
but seem to have a distinct eczema that is im-
proved by changes in food. On skin tests, they may
not have a very distinct wheal but these children
are greatly improved when they are put on acid-
ophilous milk. This changes the- whole intestinal
flora. Acidophilus bacillus is the only organism
you can recover from the bowel movement.
It is true that in most of these cases diet has
been unbalanced. There is an improper relation
between the carbohydrate, fat and protein. These
cases are rather difficult and I make a plea to stop
giving over a long period of time an excessive high
protein, as in dryco. The danger about protein
intolerance is that it is very insidious and not
realized until an intolerance has been established
and improper feeding has been going on for some
time.
One of the most recent treatments in eczema,
which was rather startling but which was men-
tioned to me by a very eminent dermatologist, is
the administration of boiled milk hypodermically
to give protein shock. The reported results have
been very satisfactory in many cases so that in
the future I intend to employ a certain amount
of protein shock as a means of clearing up some
of these difficult cases.
228
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
Dr. F. /. Krauss (Closing) : These papers have
brought out just what I was after, a discussion of
various ideas in regard to the treatment of eczema
in infancy. It is particularly interesting to hear
it from the 2 standpoints, that of the dermatolo-
gist and that of the pediatrician.
I wish to discuss 1 or 2 points that were brought
up. First of all, the skin test alone should not be
relied on; 60 to 80% are positive in cases of pro-
tein sensitization. We know that a child may be
sensitive to a skin test at one time and not at an-
other, and that complicates the feeding problem;
because we may put the child on a diet and it
will suddenly show reaction to some of the foods
to which it was previously negative. In these
cases it is a question of recurring eczema and re-
testing whenever there is a flare-up.
The metabolic imbalance should be considered,
of course, as well as the hypersensitiveness of the
skin; things over which we have no control. Men
who are dealing with allergy group these cases
with asthma and we know how many cases later
in life suffer with asthma, migraine headaches,
vomiting, etc. I do not know how to treat a child
who is sensitive to arsenic — I presume the doctor
referred to the small amount found in foods.
I do not agree with Dr. McCauley in that the
majority of the cases are of seborrheic type. When
I started to write this paper last spring I went
through my files and took every case in infancy
that had a skin test. I took 112 babies under 18
months of age. In treating them from a dietetic
standpoint there were only 7 which I could not in-
fluence by diet. Those were of the seborrheic type.
That is a small proportion in contradistinction to
what Dr. McCauley reports. I am very much in-
terested in his viewpoint and in that of Dr. Wall-
hauser. I found in this group of 112 cases that 14
were nursing babies — 7 cured, 7 unimproved; 11
were cases of malnutrition and 10 were cured, 1 im-
proved; 33 were due to milk protein, 20 of whom
were cured by drying or boiling the milk, 9 were
improved and 4 unimproved; 7 more were milk
protein, of which 5 were cured, 1 improved and 1
unimproved by omitting milk; 29 showed fat me-
tabolism, 18 of which were cured, 11 improved; 3
had a sugar metabolism, 2 of which were cured and
1 unimproved; there were 2 with egg protein, 1
cured and 1 unimproved; 6 milk protein cases put
on “sobee” diet, 3 cured, 2 improved and 1 un-
improved; cause undetermined in 7 cases, 1 of
which was cured and 6 unimproved.
In desensitizing with hypodermics of boiled milk
I have had no results. I have tried it in 3 or 4
cases. One family thought I was a very cruel
doctor, and it did no good in the cases that I have
seen. Dr. G. W. Jones, of Clovis, New Mexico, is
trying the injection of mother’s blood to desensitize
these patients and he has reported in his paper and
also in a letter to me some very interesting re-
sults. I am rather anxious to try it.
I also do not find that oranges are a frequent
cause of eczema according to my skin tests. I would
like to ask Dr. McCauley how frequently the der-
matologist makes skin tests? It is my principle
to do it in every case where there is an area free
enough to be tested. One point that Dr. Kerley
taught me was that you may very often get a re-
action on the abdomen but not on the fore-arm,
because there is an increased sensitivity of the
skin of the abdomen. Also, up over the bend of
the elbow we can get positive reactions, whereas
near the wrist the skin is not so sensitive.
I do not find that overfeeding is as common as
protein sensitization, except possibly overfeeding
by fat.
My knowledge of goat’s milk is practically nil. I
have only used it in 1 case and with no results,
although I understand in reading about the chem-
istry of goat’s milk that the chemistry is so near
that of cow's milk we cannot expect any wonder-
ful results from its use.
I am glad to hear Dr. McCauley mention the
use of baths. I think the plastering of children
from head to foot with ointments is very messy
and a horrible way of taking care of the condition.
The parts should be cleaned with borax and water.
Speaking of the reaction of milk on the skin
in these hypersensitive cases, a few months ago a
man brought me a cold cream in which he had
incorporated a certain quantity of fresh cream
and wanted me to try it out. I found that every
child who had a milk sensitivity was made worse
by rubbing this cold cream into the skin. I had
the mothers report to me within a week, and or-
dinarily if there was an irritation it was increased
by this cold cream containing the cream of cow's
milk. If seborrhea is a factor in producing this
condition of baldness, why do we not see more
eczema in females?
I presume when Dr. McCauley speaks of drink-
ing of plenty of water he refers to the nursing
mother, because giving plenty o'f water to the
babies seemed to make the condition worse.
Dr. Francis J. McCauley (Closing) : Regarding
the case Dr. Wherry spoke of clearing up in the
hospital and the condition recurring again when
the baby was taken home, I think that might be
explained from the sensitivity standpoint. That
baby was either susceptible to an infection or to
some other condition in the home, possibly a very
slight difference in the diet. In the hospital it was
taken away from the allergic factor and the con-
dition disappeared.
Dr. Nicholson mentioned the ultraviolet light.
Our limited experience corresponds with that of
most dermatologists as being unsuccessful in this
type of inflammation in which the neurocutaneous
apparatus is easily affected, resulting in increasing
the inflammation.
Regarding Dr. Krauss’ figures on the percentage
of cases in which a seborrheic element is present
in only a limited number of cases, they do not
agree with the experience of the dermatologist in
which this condition is present so constantly as to
be considered for local treatment in every case of
so-called eczema that comes under observation,
and if the simple plan of borax washings and
soothing protective applications is followed, most
cases will recover quite readily. I do not wish
to give the impression that there is not also
a constitutional factor present in many of
these cases. Allergic response may be due to
internal and external causes. Hypersensitiveness
from internal causes my be due to undigested
foods, or to a protein in some food that is prop-
erly digested ; or the patient may become sensitive
to local bowel organisms and these cases require
additional management. iBoth internal and ex-
ternal factors may be present. The dermatitis
may start as a sensitization to food or bowel or-
ganismal protein and, as a result of scratching,
end as a sensitization to the skin organisms. The
majority of cases, I believe, due to the skin or
sebaceous glands become sensitized to the protein
of the seborrheic virus from the outside.
The use of skin tests, in our experience, has
not been valuable in directing the management
of diet, as we frequently found that cases showing
a sensitivity to certain proteins could continue the
use of such substances without creating reactions.
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
229
This was especially so with regard to milk in
which a positive reaction resulted and which could
he continued in the diet without causing any ex-
acerbations. For this reason, we have practically
discontinued the use of this procedure, relying
rather on clinical observations following the inges-
tion of certain articles of diet.
In answer to Dr. Nicholson’s question regard-
ing the use of an ointment containing cream of
cow’s milk, this is easily explained by the sensi-
tization of the infant to a protein of cow’s milk
contained in this preparation.
THE MODERN TREATMENT OF
VARICOSE VEINS
V. Earl Johnson, M.D., F.A.C.S.,
Atlantic City, N. J.
Varicose veins are frequently encountered
and the writer has been impressed with
the amount of disability which they occasion.
When they become complicated the suffer-
ing is much increased and, if neglected,
the patient may become an invalid for
life. It is in the interest of the many suffer-
ers from varicose veins that this communi-
cation is written.
In the past these cases have been treated
conservatively or radically. In the conserva-
tive treatment the patient was given an elastic
stocking or bandage to wear. This was fol-
lowed rather indifferently, both by the physi-
cian and patient. The patient, usually a
woman, objected to the presence of the band-
age as being unsightly. The radical treatment
consisted of operations which removed the
varices, or the entire saphenous vein was re-
moved from groin to ankle. Neither of these
methods (conservative or radical) gave re-
sults satisfactory to the parties concerned. The
conservative always failed, except in cases
where the veins were very small, but it did
accomplish one thing when the treatment was
sufficiently persistent ; it did keep the veins
from getting worse. In fact, that was all that
was even hoped for. The radical method was
applied when the veins were extremely di-
lated, usually the entire saphenous trunk, or
when ulceration had supervened. Very radi-
cal procedures were then necessary and the
surgical treatment was successful only in so
far as the efficiency of the operation allowed.
The most successful was the Mayo method in
which the great saphenous vein was ligated
at the sapheno femoral junction, and the
saphenous vein removed as far down as the
ankle. This was, at times, supplemented by
additional incisions, with excision of outlying
varicose bunches. This method, however, car-
ried a direct mortality of 1 in 200 and a sub-
sequent mortality of 1 in 200 ; that is, a total
mortality rate of 1% resulted from the radi-
cal surgical treatment. This, in itself, caused
many physicians to advise against operation
and some conservative surgeons refused to
operate. One of the real drawbacks to the
operative treatment, from the patient’s stand-
point, was the economic factor. The period
of disability following operation was usually
about 6 weeks and sometimes much longer.
The treatment of varicose ulcers was fre-
quently unsuccessful, regardless of how radi-
cally the operation was done. The above
status of the former treatment of varicose
veins is not exaggerated and it is not sur-
prising that other and better methods have
been sought and that the injection method of
treating these cases has been developed, and,
fortunately, this method marks a great ad-
vance in handling these cases.
It is very surprising, however, that the
method has not enjoyed the full sanction of
the rank and file of the profession. It is also
unfortunate that more physicians do not know
more than they do about this method, its ap-
plication and end-results. It is a fact, that
comparatively few varicose vein cases are re-
ferred for treatment. Sometimes this is due
to the fact that the examining physician does
not know about such treatment at all, or if
knowing, he does not know anyone doing that
work. Most often it is due to the fact that
examination does not disclose the presence of
the veins, and again, when they are found
they are passed over as an insignificant find-
ing. If I can succeed in bringing this method
to the attention of a few more men, and can
impress upon them the necessity of treating
varicose veins, when found, I will feel that
the time expended hereon has been well worth
while.
The term “varicose veins” may be applied
230
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
to veins in any part of the body, but, due to
common usage, it has come to be associated
with varicose or dilated veins of the lower ex-
tremities. That is the application in this
paper.
If one examines the accompanying plates,
showing the normal anatomy of the leg, it is
apparent that there are 2 principal sets of
veins. Those beginning over the top of the
The posterior veins are known as the short
or lesser saphenous veins. The long internal
chain of veins becomes known as the long or
great saphenous vein. Both of these sets of
veins run in the subcutaneous tissue through-
out their course and both sets have communi-
cating veins which join them with the deep
veins. These deep veins are entirely beneath
the muscle fascia layer.
Plate 1
Legend: Illustrating the 2 main venous channels of the leg below the
knee. Those beginning about the internal malleolus ascend as the great
saphenous vein on the anteromedial aspect of the leg, while those begin-
ning about the external malleolus pass up the posterior surface of the leg
as the lesser saphenous.
The course of the great saphenous above the knee and relations about
the fossa ovalis are shown. The connecting veins between the super-
ficial and deep veins are well illustrated, as well as is the relationship
between the superficial veins and the muscle fascia.
foot and around the internal malleous unite
and extend upward to the inner and antero-
medial aspect of the thigh to the groin, where
it joins the femoral vein about 2 inches below
Poupart’s ligament. Those beginning about
the external malleolus extend up the posterior
surface of the leg, over the calf, and end in the
popliteal space where they join the popliteal
vein. The popliteal vein then passes to Hun-
ter’s canal where it becomes the femoral vein.
Thus, there are 3 sets of veins in the leg
that one has to consider in the diagnosis and
application of treatment— the superficial, the
deep, and the communicating. Each of these
systems has valves placed at irregular inter-
vals and usually just distal to where a branch
joins. The presence of normal valves
throughout prevents varicose vein formation,
but when some of them give way and become
incompetent, then varicose veins are sure to
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
231
develop, and the extent and type of varicose
veins that will develop is dependent upon the
number of valves involved.
Etiology of Varicose Veins
Much has been written on the etiology of
varicose veins and a vast amount of experi-
mental work has been done in an effort to
locate the cause of the condition. A review
of this work would not be in the scope of this
manuscript. Among the theories advanced
are: (1) Congenital weakness of the vein
walls or valves, or both; (2) that there de-
velops a loss of nerve and muscular tone of
the vein wall; (3) that the cause is an in-
fectious one — a low grade periphlebitis or
phlebitis secondary to emboli, or through or-
ganisms being brought to the vein by the blood
stream or by extension from adjacent infec-
tion; (4) that the endocrine system is respon-
sible; (5) that occupation is the principal
cause.
It is difficult to account for the cases seen in
young people unless congenital weakness is
the etiologic factor. The youngest patient
was 9 years of age. We know that varicose
veins develop following infections such as
scarlet fever, pneumonia, rheumatism, typhoid
fever and influenza. We also know that vari-
cose veins may follow trauma, and we have
seen them follow a superficial phlebitis. By
far the most frequently associated factor is
occupation. We find them in people whose
occupation requires a great deal of standing —
barbels, policemen, waiters. It is probable
that in the great majority of cases we have to
deal with both a congenital weakness and the
associated factors such as infections, occupa-
tion and influence of conditions producing an
increased intraabdominal pressure, like con-
stipation, asthma, chronic cough. Besides the
above types of cases we see varicose veins
secondary to obstructive pathology — fibroid
uterus, intraligamentous pelvic cysts, tumors
of the inguinal glands, cirrhosis of the liver.
We also see them in the presence of marked
cardiac decompensation and during and fol-
lowing pregnancy.
Diagnosis
The diagnosis of varicose veins is perfectly
obvious. It is necessary, however, in the av-
erage case, to have the patient stand flat on
his feet. The mere diagnosis of varicose veins,
however, is not sufficient. One must de-
termine, as far as possible, the etiologic fac-
tor. It should be easy to rule out those cases
due to obstructive lesions outside of the vein ;
cirrhosis of liver, cardiac decompensation,
fibroid uterus, pelvic cysts, inguinal adenitis,
advanced pregnancy. It then matters little,
so far as relief to the patient is concerned,
what is the etiologic factor, but it is still im-
portant to determine how extensive the veins
are. Is there only a short segment involved?
Is the entire great saphenous vein involved or
the entire lesser saphenous? Is the superficial,
deep or communicating system at fault? Is
there a combination of any of the systems?
It is obvious whether the varix is a short one
or whether the entire length of either the
greater or lesser saphenous is involved, but in
order to determine whether the superficial
system is alone involved, or whether the sys-
tem and communicating systems are simul-
taneously involved, or whether the superficial,
communicating, and deep systems are all in-
volved, requires the application of 2 tests.
Trendelenburg Test
(1) Have patient lie flat on the table.
(2) Elevate the leg so that the veins be-
come empty.
(3) Place the radial edge of the thumb
across the upper thigh and make pressure
about 3 in. below Poupart’s ligament and
medial to the pulsating femoral artery.
(4) Have patient stand up, meanwhile keep
the hand applied as directed, as this obstructs
the great saphenous vein. Now, the test de-
vised by Trendelenburg advised that the hand
obliterating the saphenous vein be removed
and immediately following this the column of
blood would fill the great saphenous trunk
with a thud. In other words, the entire trunk
would become filled instantly. This would
occur when all the valves of the great saphe-
nous were incompetent. Instead of doing the
232
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
above as soon as the patient stands, continue
to apply the pressure to the saphenous origin
and if the veins fill slowly from below up-
ward one knows that the valves of the com-
municating veins are intact. Then, release the
pressure on the saphenous and if the entire
saphenous trunk fills immediately one knows
that the valves are incompetent in that system.
This is the Trendelenburg positive test. If,
Plate 2
Legend: The negative, positive and double posi-
tion Trendelenburg test. The patient’s leg is ele-
vated and pressure is made on the great saphenous
vein and the patient is asked to stand up. (a). If
the veins remain empty or fill up slowly, from
below, and do not change in size after the pressure
is released, the test is negative. There is no re-
versed flow in the saphenous system, (b). If the
veins remain empty so long as pressure is main-
tained, but fill up from above with a sudden gush
when the pressure is released, the test is positive.
The flow of blood in the saphenous vein is re-
versed. (c). If, however, the veins fill up suddenly
on standing, in spite of saphenous compression,
there is a reflux from the deep veins. Releasing
the compression may produce a further filling of
the veins, thus making the test doubly positive.
This latter condition, indicating a valvular insuffi-
ciency of the communicating veins, is not favor-
able to the injection treatment and is a frequent
cause of recurrence. — (Diagram from Homan).
on the other hand, the veins below fill very
rapidly, one knows that the valves of the com-
municating veins are incompetent. If now the
pressure on the saphenous is released and the
entire saphenous fills with a splurge, this is
known as the “double positive’’ Trendelenburg
test. If the veins below fill rapidly and when
the pressure on the saphenous is released there
is not a rapid filling of the trunk from above
downward, then we have the Trendelenburg
negative, denoting that the valves of the
saphenous trunk above the varices are com-
petent but that some of the communicating
valves are incompetent.
There now remains another very important
point to determine. Having determined the
condition of the superficial system, it is neces-
sary to determine whether these are dilated
and varicose as the result of obliteration of
the deep veins obstructed from a previous
phlebitis or otherwise. In other words, are
the superficial varices compensatory in their
nature? If the superficial veins are obliterated
by treatment, are the deep veins competent
to care for the venous circulation? This is
determined by Perthe’s test, as follows : Place
a tourniquet about the upper- third of the thigh
while the patient is in the standing position,
only sufficiently tight to obstruct the super-
ficial veins; the patient is asked to walk to
and fro for about 2 minutes ; the leg muscles
squeeze the blood out of the deep veins and
aspirate the blood from the varicosites; and
the superficial veins become diminished in
size. If these veins do not diminish in size the
deep veins are not competent.
So far we have diagnosed the presence of
and the type of varices. Now we have come
to the clinical side of the case. Many of these
patients present themselves for treatment be-
cause of pain in the calf or joints. A differ-
ential diagnosis must exclude Buerger’s dis-
ease, neuritis (this includes pressure pain of
pelvic tumors), tabetic pains, arthritis, and
weak feet. Actually, the only important ones
of those to rule out are: (1) Buerger’s dis-
ease, as the veins are not the cause of the pain
in this disease, and (2) pain produced by pres-
sure of pelvic or inguinal masses. Buerger’s
disease is easily ruled out by determining the
presence or absence of pulsations of the dor-
salis pedis and posterior tibial arteries. Pelvic
tumors and inguinal tumors are ruled out by
adequate examination. The other conditions
are actually benefited by treatment of the
varices, thus improving the circulation. This
improvement is especially marked in cases of
arthritis of the knee joint associated with vari-
cose veins and pain due to weak feet.
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
233
Treatment
The treatment should be approached by 3
different methods :
(1) The injection method: This can be de-
pended upon to give excellent results when
used on properly selected cases. The proper
cases are tabulated :
(a) Those cases where there are scattered
or segregated varices. This includes those on
the thigh, as well as the lower leg.
(b) All cases where the posterior veins (the
lesser saphenous trunk) are alone involved or
when combined with the great saphenous
trunk, provided the latter is not involved
higher than 4 or 5 in. above the knee. If the
varices are particularly large, amounting to
venous sinuses, this method may fail to give
a permanent result when used alone.
(2) Operative ligaturing of the great saphe-
nous followed by injection treatments.
(a) This is indicated in all cases giving a
positive Trendelenburg test. That is, when
the entire great saphenous chain is involved.
Much more rapid results are obtained by this
combination. While it is possible to inject the
entire trunk, in segments, and even at the
saphenofemoral junction, the method is far
from being as safe as ligation.
(b) Those cases that have progressed so
far that the veins have, literally, become pools
of blood, instead of having the outline of a
vein. One reason why these cases fail to give
results with the injection method is because
the intima has been so stretched as to be
mostly scar tissue and therefore cannot react
to the injection solution to form a good
thrombus.
(3) Operative treatment. This is indicated
for those cases giving a Trendelenburg double
test. In these cases the valves of the great
saphenous trunk are incompetent and, in ad-
dition, the valves of the communicating and
deep veins are also incompetent. Ligation
would not control the reflux from the deep
system. The procedure of choice in these
cases is to ligate the great saphenous vein
at the saphenofemoral junction and then strip
the saphenous vein as far as the knee and ex-
pose the trunk below the knee so as to be
able to ligate the communicating veins and
remove the varices. In some of these cases it
has been possible to obliterate the veins be-
low the knee instead of excising them. This
latter may first be tried, but the great saphen-
ous must be ligated first.
Technic of Ligating Saphenous Veins
This operation is done under local infiltra-
tion anesthesia. The line of incision is made
2 fingers’ breadth below Poupart’s ligament
to the inner side of the anterior surface of the
thigh. The line of incision is infiltrated with
1 % novocain-adrenalin solution and the in-
cision made about 1)4 in. long through the
skin, in a transverse direction ; then the sub-
cutaneous tissue is infiltrated with the same
solution. The vein is then exposed and 2
cat-gut ligatures are placed and tied and the
vein divided between the ligatures. Do not use
artery clamps ; in order that the intima may be
traumatized as little as possible. The incision
is then closed with black silk or Michel clips.
I use the latter because I feel that a source of
infection is thereby eliminated. These clips
are removed on the third or fourth day. The
procedure may be done in the office and the
patient allowed to go home and follow usual
routine or it may be done in the hospital and
the patient kept in bed for 5 days. Either
method is safe.
Technic of Injection Treatment
There have been many solutions advised
and used with varying results. My exper-
ience with invert ose (aqueous invert sugar
solution) 60% or 70% has been entirely satis-
factory. In the beginning, I used 20%
sodium chloride, but gave it up because of the
severe pain occasioned by each injection.
Some patients complain of a heavy feeling of
the entire leg, others of a mild pain in the in-
jected areas and a few have felt a mild sen-
sation of electric shocks, but this immediate
pain always disappears very shortly after they
have walked out of the office and the subse-
quent course is entirely painless. In a few
cases there has been a moderate soreness last-
ing 2 days.
234
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
Technic for Invertose Injections
(1) The syringe, a 10 c.c. Luer-lok type is
filled with the invertose solution, and a 23
gauge, short, bevel needle attached.
(2) The patient has been standing during
the period of filling the syringe and the veins
are now distended. The vein is selected and
the skin over this vein painted with tr. iodin.
Now the patient is asked to lie down on a low
table and the needle inserted into the vein
without delay. Do not lose any time after the
patient lies down or the vein will collapse.
After the needle is in the vein have an assist-
ant strip the blood out of the segment to be
injected and hold the skin taught during the
entire procedure of injecting. Then inject the
solution fairly rapidly. Be sure your needle
is in the vein. As soon as the injection is
completed, note the time but don’t remove the
needle. Now allow 5 minutes to pass before
the assistant releases his pressure and before
removing the needle. Then apply a small
sterile pad, with a strip of adhesive, over the
puncture wound. Apply an “Ace” bandage
from ankle to above the injected area.
If one has difficulty in keeping the vein dis-
tended long enough to insert the needle, a
tourniquet may be applied above the selected
vein while the patient is standing. If still
the vein collapses as soon as the patient re-
clines, then the injection may be given with
the patient standing. In the latter cases, as
soon as the injection is completed it is wise
to have the patient lie down for the 5 minute
pressure period.
The patient is then allowed to leave the
office and go about his usual duties. Injections
are given in the same leg at weekly intervals,
but one may inject 2 or 3 veins in the same
leg at one time. The “Ace” bandage should
be worn continuously during the entire course
of treatment in order to obtain the best re-
sults.
The average cases will require from 3 to
5 injections for each leg. The worst case of
uncomplicated varicose veins in my practice
required 6 injections after the great saphenous
had been previously ligated at the saphenous
opening. However, I used 10. 15 and 20 c.c.
injections for this particular case. So far I
have not had a failure with this preparation
(invertose), but should I run into such a case,
I would follow the suggestion made by de
Takats and use 70% invertose and 30% salt
solution mixed in equal quantities.
Mechanism of Obliteration of Veins
with Solutions
Much space has been used to present the
exact changes occurring after the injections
have been given, and experimental work has
been produced to prove the exactness of state-
ments and accepted theories. To be concise,
the solution acts as a chemical irritant on the
intima, causing it to become swollen, fibrin is
deposited and red cells become entangled in the
fibrin network, and within a few hours the
vessel is filled with a blood clot. After a few
days (4 to 6) organization of this clot is
evident by penetration of the clot by fibro-
blasts and the presence of new capillaries.
These new capillaries spring from the intima
out to the clot, thus anchoring the thrombus.
Contraction of the clot, with narrowing of
the vessel, proceeds until at the end of about
3 or 4 weeks the original varicose vein can be
felt as a small cord beneath the skin. There
are 2 principal reasons why the incidence of
embolism in this type of treatment is so small.
The first reason has been given above, in
which it was shown that the clot is fixed to
the intima with newly formed blood vessels.
The second reason is that the circulation in
varicose veins is reversed. This has been
positively proved by injecting lipiodol into a
varicosed great saphenous and then watching
the behavior of it, inside the vein, under a
fluoroscope. The lipiodol particles are seen
to go downward, instead of upward toward
the femoral artery.
Provided cases are properly selected for the
3 forms of treatment, one can feel confident
of promising a cure of the veins present, but
other veins might become varicose at some
time in the future.
The most promising group of cases consists
of those selected for the injection treatment
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
235
alone; all of which can be cured. This
is naturally so because the disease has not
progressed to the extent that requires op-
erative treatment, either combined with in-
jections or alone.
As compared with the old forms of treat-
ment, in which operation was the only radical
treatment, a very decided advance has been
made, not only from the standpoint of cures
and improvements, but most especially from
the standpoint of mortality of the treatment.
The treatment of varicose ulcers has not
been attempted in this communication because
it is a condition warranting a separate presen-
tation.
Conclusions
In the foregoing paragraphs it has been my
desire to discuss the treatment of varicose
veins from a purely practical and clinical
standpoint. I particularly wish to make 2
points clear.
(1) That the injection treatment of vari-
cose veins is now a legitimate procedure. Be-
cause of this established fact, it should be
recognized more widely by the rank and file
of the profession, and furthermore, patients
should be advised of this form of treatment,
and they should be encouraged to have their
varicose veins treated before they become so
extensive as to require more than injection
treatments. The next generation, if the above
advice is followed, will be treated so early in
the stage of the varicose vein development
that the injection treatment alone will suffice.
(2) That the injection treatment of vari-
cose veins is not a panacea. All veins can not
be so treated. It is not now sufficient to say :
“Varicose veins; injection treatment indi-
cated.” It is necessary to segregate the dif-
ferent types of veins and apply the appro-
priate type of treatment. Some cases require
surgery alone, while others require a combina-
tion of the two, and still others should not be
treated radically at all, because they are com-
pensatory in nature.
INTRADURAL CAUDAL ANESTHESIA
AS AN OFFICE PROCEDURE
G. T. Spencer, A.B., M.D.,
Hornell, N. Y.
The advantages of intradural anesthesia are
its low toxicity, its totality, and the complete
relaxation of such voluntary muscles as are
under its influence. No other anesthesia gives
with equal safety either so deep insensibility
to pain or such entire muscular flaccidity. Its
great disadvantage is the vascular depression
caused when the splanchnic nerves are
blocked. The use of an anesthetic solution of
high viscosity and specific gravity, however,
enables the operator successfully to limit the
anesthetized region by mere control of posi-
tion of the patient. Such a solution is now
marketed under the trade name of gravocciin,
and produces perfect caudal anesthesia via
the intradural route. It has been described
by its originators, Pitkin and .McCormack, and
by its proper utilization blocking of the
splanchnic nerves and dilatation of the splanch-
nic blood vessels are avoided and complete
anesthesia is secured, for more than 2 hours,
of the lower 4 in. of the rectum, the anus,
cervix and vagina, perineum, scrotal integu-
ment and part of the scrotal contents, the
penis, urethra, prostate, and floor of the blad-
der. The successful attainment of so deep
and lasting caudal anesthesia opens new fields
for office procedures, otherwise necessarily
performed in a hospital, in urology, gynecology
and proctology. These operations are limited
only by the convenience of the operator and
the severity of aftermath, for the patient can
be at home, in bed if necessary, before the
anesthesia has worn off.
Gravocain is usually injected while the pa-
tient is in a sitting posture, with elbows rest-
ing on knees, the back bowed outward and
the head inclined forward. Since experience
has shown that 0.2 c.c. of this solution yields
complete caudal anesthesia lasting 2 hours,
it is my custom to introduce it with a tuber-
culin syringe to permit more accurate dosage.
No admixture with spinal fluid is necessary,
236
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
and anesthesia is almost invariably attained
within 5 minutes. I have had no failures. Im-
mediately after introduction of the solution
and withdrawal of the needle the patient is
instructed to sit as erectly as possible in order
to minimize leakage of spinal fluid. He is kept
in this position until anesthesia sets in, and
then placed — or places himself — in the semi-
recumbent posture for the operative work to
be done. The third or fourth lumbar inter-
space has proved most satisfactory as the point
of injection, for if injected higher the solution
anesthetizes, to variable extents, the higher
nerve roots as it sinks to the bottom of the
dural sac.
When locomotion is interfered with, the ab-
ductors of the thigh are first and most affect-
ed, since their nerve supply is from the sacral
plexus. If the subject attempts walking too
soon, in such case, he stumbles over his own
feet and his knees interfere. He cannot sep-
arate his lower extremities successfully until
the abductors’ nerve control is reestablished.
There occurs little or no paralysis of the thigh
abductors, because their nerve stimuli proceed
through the third and fourth lumbar roots via
the obturator nerve.
Intradural caudal anesthesia was given in
the office to 24 ambulant patients, with an av-
erage dose of 0.22 c.c. gravocain. at either the
third or fourth lumbar interspace. The av-
erage time elapsing between administration
and unaided departure from the office was 1
hr. and 24 minutes. The only advice given
these patients concerning the anesthesia was
to keep their heads and shoulders higher than
their hips until at least 3 hours had passed.
Some of them walked home, some took cabs,
and some drove their own cars. The series
comprised the following: fulguration of
verumontanum, 3 ; injection of vas, 1 ; fulgur-
ation of median bar, 3; intraprostatic injection,
4 ; fulguration of caruncle, 1 ; relief of acute
retention from urethral stricture, 1 ; internal
urethrotomy, 1 ; circumcision, 1 ; diagnostic
cystoscopy, 2 ; injection of hemorrhoids, 5 ;
fulguration of cyst of bladder neck, 1 ; open-
ing of ureterocele with scissors through cysto-
scope, 3. The ages of the patients ranged
from 26 to 74 years. No preliminary
narcotics or sedatives were given. The con-
dition of the heart, blood pressure, and lungs
was given no consideration. Pallor and faint-
ness occurred twice, in each case before the
anesthetic wras given, and were recovered from
by the time anesthesia was complete. There
was 1 post-puncture headache. (The patient, a
male of 26, left the office at 10.30 p. m. with
instructions to go home to bed. He did so, but
arose again at 1.30 a. m. and drove a milk
wagon for several hours.) There was no such
dread of repetition as general anesthesia
causes. One patient received intradural
caudal anesthesia 3 times, and 4 others took
it twice apiece.
Conclusions
(1) Intradural caudal anesthesia with
gravocain seems to be a safe and conservative
office procedure.
(2) . Vascular depression, the most constant
deterrent to spinal anesthesia in general, is
avoided because the splanchnic nerves are not
blocked.
(3) Certain contraindications usually re-
cognized as pertaining to intradural anesthesia,
such as hypotension, cardiac weakness or in-
competency, limited pulmonary capacity, and
extreme hypertension, do not apply to intra-
dural caudal anesthesia.
(4) The technic is simple and the dosage
small and accurate.
(5) Anesthesia is rapid in onset and en-
dures from 2 to 3 hours.
(6) Patients undergo it gratefully and re-
peatedly since it causes no such dread of
repetition as does general anesthesia.
A SKIN TEST FOR WHOOPING-COUGH;
PRELIMINARY REPORT
Charles V. Craster, M.D., D.P.H.,
Health Officer of Newark,
and
Ellis Smith, M.D.,
Superintendent Essex County Isolation Hospital,
Belleville, N. J.
With the exception, perhaps, of measles,
there is no more difficult disease to control
than whooping-cough when it becomes epi-
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
237
demic in character. The reason is the pres-
ence at such times of great numbers of un-
recognized and undiagnosed cases, in which
children with spasmodic coughs, not quite
severe enough to show or entirely lacking in the
tell-tale whoop, are unsuspected of being true
cases of pertussis, and are enabled to broad-
cast infection among susceptible persons of
all ages. The diagnosis of whooping-cough,
even by the physicians, has depended upon
history of the child’s cough, of his having
been exposed to a known case, or to acciden-
tal occurrence of a cough paroxysm in the
presence of the physician. The laboratory
diagnosis of pertussis by sputum examina-
tion, or by the plate method, is seldom at-
tempted as a routine procedure by practicing
physicians or the local health department.
The inciting cause of whooping-cough, the
now generally accepted Bordet-Gengou bacillus,
has been characterized by a signal absence of
toxin formation in culture, and a remarkably
low virulence toward laboratory animals. Cul-
tures of the bacillus, in strength of billions
of bacteria per cubic centimeter, have been in-
jected into small guinea-pigs without produc-
ing untoward results. Similarly, in use of the
vaccine for prophylaxis and curative action in
cases of whooping-cough, children have shown
a remarkable tolerance for quite enormous
doses of the bacillus. The toxin of this bacil-
lus, although of only limited toxic power, is
capable of producing a very definite amount
of immune bodies in the blood stream of the
infected individual, as is shown bv the high
degree of immunity following an attack of
whooping-cough. Second attacks are so rare
as to be curiosities of medicine, and this im-
munity is presumably of life-long duration.
In 1928, M. V. Pechere, of Brussels, re-
ported the results of intradermal tests upon
104 children, 70 of whom gave positive re-
actions and in 60, or 84% of these, whooping-
cough was actually present. Of 23 children
with a negative reaction, 16% had whooping-
cough and 84% had typical paroxysmal
coughs. Among 10 children in whom whoop-
ing-cough had been definitely diagnosed, there
were 10 positive reactions. In 24 cases of
pertussis in process of evolution 20 gave posi-
tive skin reactions, while in 7 children who did
not have whooping-cough, 6 gave negative re-
actions. Pechere was of the opinion that the
test would be useful for early diagnosis of the
disease.
For the purpose of determining the^ charac-
ter of reaction described by Pechere and use-
fulness of the test in hospital work, the writers
decided to test out this action in patients suf-
fering from acute attacks of whooping-cough
and in a number of children free from that
disease. In this intradermal test the antigen
used was a vaccine made from stock culture
of the Bordet-Gengou bacillus containing on
the average 1,000,000,000 bacteria per cubic
centimeter. The amount used for each in-
tradermal test was 0.05 to 0.1 c.c., the point
of injection being the forearm.
In this preliminary work the group of chil-
dren was composed of those in the hospital
wards at that time, suffering from whoop-
ing-cough in various stages of severity, from
the recently arrived case with frequent par-
oxysms to the case nearing the end of a 6
weeks’ quarantine period. There were 11
children injected intradermally ; 6 with 0.1
c.c. and 5 with 0.05 c.c. of the stock vaccine.
In all these cases the results were the same.
There appeared at the site of injection, with-
in 12 to 24 hours, a distinct area of redness
varying from J/2 to 1 inch in diameter. The
reaction, however, was transient in character
and within 48 hours faded, leaving nothing
visible but the point of injection. There was
no pain or discomfort and no subsequent scal-
ing or pigmentation.
For the purpose of finding how far the
skin reaction could be used to show the ab-
sence or presence of immune substances in
the blood of average individuals, a group of
24 children were tested, 10 of whom had his-
tories of a previous attack of whooping-cough
and 14 who had no such history. Among the
10 with histories of whooping-cough, there
were 8 positive and 2 negative reactions. These
results would indicate the very definite pres-
ence of immune bodies in 80% of recovered
cases. In the 2 negatives, the possibility of
errors in the original diagnosis cannot alto-
gether be excluded. With regard to the other
238
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
group, the results were not quite so clear-cut.
Among the 14 children having no histories of
a previous attack of whooping-cough, 7 were
positive and 7 negative. Of the 7 positives, 2
were very slight reactions and 1 was negative
at the end of 24 hours. The results in this
group could not be said to be conclusive and
did not parallel the experiences of Pechere
who had a much higher percentage of nega-
tive tests. His group was, however, small ;
only 7 children.
These results substantiated the claims of
Pechere, that there is present in the individual
suffering from whooping-cough very definite
antibodies which are specific against the
Bordet-Gengou bacillus. This was particularly
clear in our group of children suffering from
active symptoms of whooping-cough, all of
whom showed positive skin reactions.
The conclusions derived from this study, al-
though covering only a small group of super-
vised cases, are significant enough to suggest
use of the intradermal test for whooping-
cough as a means of quick diagnosis, especially
where there is immediate need of segregation.
This test can also be used to determine suscep-
tibility to whooping-cough, and enables us to
separate susceptible children from suspected
cases and to determine whether prophylactic
doses of whooping-cough vaccine should be
administered.
Summary
The group of children upon whom intra-
dermal tests for whooping-cough were made,
although small, indicates without doubt the
constant presence of an allergic skin reaction
in active cases of the disease.
The intradermal dose of the antigen, whe-
ther 0.1 or 0.05 c.c., provoked the same re-
action in all the children.
The transient character of the area of red-
ness, appearing quickly between 12 and 24
hours after injection and disappearing more or
less completely within 48 hours, is in keeping
with the known low toxicity of the Bordet-
Gengou bacillus.
In the group of 24 children tested for sus-
ceptibility, 80% of those having a history of
a previous attack of whooping-cough showed
positive skin reactions. In the group having
no record of previous whooping-cough, 50%
were positive and 50% negative.
Further work along these lines with a
slightly stronger antigen is in contemplation.
SOME THOUGHTS ON MEDICAL ECO-
NOMICS AND MEDICAL PRACTICE
S. Rubinow, M.D.,
Newark, N. J.
The symposium on medical economics
which appeared in the November issue of our
State Society Journal is so excellent, so rich
in ideas and originality, that the editor de-
serves the gratitude of the members for giv-
ing it a proper place and for calling the pro-
fession’s attention to it editorially. Not that
the subject is new; indeed, we are fed up with
it of late in the medical and lay press, but it
is presented so clearly and eloquently by all
the speakers that any member, if he devotes a
little time to reading these addresses carefully,
will be fully aware of. the magnitude of a
problem which now worries the best minds of
our profession. He will see that here is a
topic of the utmost importance to the profes-
sion and to himself, whatever his age, his
standing, his line of work, or his economic
status may be. He will also realize that he
must make up his mind as to his own views,
as to his own attitude toward a new trend in
practice of medicine, so as to be ready to act
accordingly when the time comes that some
practical plan shall be offered him for con-
sideration and for vote.
It is gratifying to notice that all 3 speakers
are fully in accord ; there is no disagreement
among them on any vital point. They not only
agree among themselves but all support the
views of Dr. Harris, recently President of the
American Medical Association, and of Drs.
Pusey, Bevan and West. It appears that they
all agree as follows :
( 1 ) They are opposed to state medicine.
(2) They agree in the desire and efforts to
preserve our individualistic medicine.
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
239
(3) They agree that the medical profession,
as it stands today, is not doing all it should
to bring the fruits of scientific achievement to
all classes of the people.
(4) They agree that the cost of illness is
not within the means of the majority of the
people.
(5) They warn the profession that if it
does not remedy existing conditions, by its
own efforts, outside forces will attempt to do
so, and will lower the dignity and usefulness
of the profession and make the doctor a hire-
ling of big capital ; in short, will introduce
some kind of public control over medicine.
Such is the issue. What is to be done
about it?
In their answers to this vital question, the
speakers likewise agree fully. The profession
must take into its own hands the remedy, must
change conditions so as to render adequate
scientific aid to the people, must reduce the
cost so that it shall be within reach of every
one, and must by adequate service gain the
confidence of the people. But how are these
pia desiderata to be brought about? Here,
after all, lays the crux of the whole matter.
Dr. Harris made the following definite pro-
posal : Every county society shall organize all
its members and establish a medical center,
owned, controlled, and managed by the so-
ciety itself. This center should function as
a pay clinic with every reputable physician
a member on the Hospital and Clinic Staff.
Services rendered should be complete, and
charges made according to nature of services
rendered and the means or economic status of
the patient. After necessary over-head ex-
penses are deducted, the balance would be
paid to the physicians on the basis of services
rendered. Later, arrangements should like-
wise be made for the care of patients at their
homes, as well as for hospitalization when
necessary. Obviously, this institution is not
meant for the rich class, who can afford to
have the best services privately, but for the
large middle-class of our people.
Drs. Hall, McBrayer and Reik endorse the
Harris plan but, ideal as it may seem, the
writer of these lines feels convinced that it is
utterly unworkable and is destined to remain
a scheme on paper only. To begin with, the
medical profession traditionally has always
been poor material for any concentrated ef-
fort. A county medical society has no uni-
form membership, such as a labor union has ;
there is no resemblance of equality among
members as to education, achievements, per-
sonality, ethics, etc. One cannot see how, in
a large community with several hundred
physicians, all or even a majority of them
could be attached to the proposed center on
an equal basis.
The difficulties met by the managing board
would be no less than unsurpassable. A physi-
cian friend, discussing this plan, expressed
himself thus : “I would rather see some kind
of state medicine.” It might be workable in
a small community, with a dozen or so medi-
cal men, but originally the issue arose, not
in small communities, but in large centers.
In spite of great interest in the problem,
the writer is not aware of any other definite
plans to improve upon the present method of
practice of medicine. It is true that the na-
tional “Committee on the Cost of Medical
Care” has not yet completed its elaborate sur-
vey of all the contributing factors and one
must patiently wait for a complete report and
some definite recommendations. But, acknowl-
edging the very high standing of the mem-
bers of that committee, one wonders whether
its membership includes an ordinary prac-
titioner of medicine, one who in his daily and
hourly work is confronted with all those
countless details which arise in any sphere of
purely human relations and which slowly,
gradually, but persistently, have brought the
big issues to the front. Such a practitioner,
small as his voice may be, is entitled to a
hearing.
Let one stop and consider what are the fac-
tors which in the last decade or so haA^e
changed the character of medical practice and
contributed to the high cost of medical care
to such a degree that it has become a national
issue? Realizing, as every one must, that a
certain rise was inevitable on account of the
diminished value of the dollar, the higher cost
of all other commodities and the higher stand-
240
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
ard of living, the following 3 factors are, in
the writer’s opinion, at the base of the whole
issue.
(1) Gradual disappearance of the general
practitioner, the family doctor, and the rise of
specialists. The practitioner always was, and
is today, reasonable in his fees and hardly any
complaints are made against him. He is in
closer contact with his patients, better
acquainted with their family standing, and in
most cases money matters between them are
being arranged without dispute or hard feel-
ing on either side. He will always try to place
his patient in the most favorable condition
without undue strain on the victim or his
family. There is no reason whatsoever why
he cannot take care of the great majority of
cases of illness. A somewhat more adequate
preparation of himself is desirable, and could
be achieved by adding 1 year more to his
medical course, taking this year from the pre-
medical college requirements. Not so with
the specialist. After having trained himself
in a certain branch of medicine (this training
often of quite a short duration), he believes
himself on a much higher plane and entitled
to higher remuneration for his services. There
is no sound reason why the young man who
shortly after concluding his internship starts
as a pediatrician, or nose-and-throat man, or
dermatologist, or any other kind of specialist,
should be entitled to fees higher than those
of a general practitioner. It may be a simple
conjunctivitis, an every-day nasal condition, a
healthy infant requiring a routine formula
which may take 2 minutes to determine, for
which the specialist charges double the amount
of what an experienced practitioner charges
for half an hour’s general examination of his
patient. This by no means applies to the ex-
pert, but the average specialist is not an ex-
pert ; he is only a practitioner in a limited
field. Experts are rare, and should handle
only cases referred to them by the practitioner,
general or special. In a city of 500.000 popu-
lation, one will find hundreds of specialists
and hardly a dozen experts. One must admit
that the present specialist’s fee, which is
charged often not for the nature of his services
but for his alleged higher standing, is not
justified.
(2) The most serious factor contributing to
the high cost of medical care is found in use
of the latest developments of medical science,
requiring often costly procedures in rendering
a diagnosis. Various laboratory examinations,
including use of x-rays, are often necessary
and are at present quite costly. It is true, that
more than 20% of patients visiting the physi-
cian are suffering from minor ailments and
do not need more laboratory tests than the
well-equipped practitioner is easily capable of
making, but the other 30% constitutes quite a
problem to be reckoned with. Complete and
repeated blood examinations, blood chemistry
tests, gastric radiography series, pyelographs,
electrocardiograms, metabolism tests, etc., are
at times necessary and often not within the
financial possibilities of the patient. It greatly
handicaps the medical man who has for his
clientele the workingman, the white collar
man, and the small tradesman. One can easily
understand that the private laboratory, with
considerable overhead expense, having but 2
or 3 Wassermanns to do. must charge $5 each,
while it would not require much more time
and labor to make 20 or 30 similar tests at the
rate of $1. The roentgenologist’s charges of
$50 to $100 for gastric series are, again, due
to big overhead, to time utilized only in part,
to the comparatively small number of such
cases. The active laboratory working full
time could reduce these fees to $10-$20.
Here iij a field where the organized County
Medical Society might render invaluable ser-
vices to the community and its practitioners
by establishing a completely equipped labora-
tory, to be run on business principles, on a pay
basis, with charges commensurate with the pa-
tient’s financial standing, compensating ade-
quately all professional workers, and paying
interest on the invested capital but without
further profits. By engaging an adequate
number of technicians and a competent staff
of scientific physicians, such a laboratory
could serve the needs of the whole county
and to a great extent reduce the cost of all
laboratory examinations.
The writer feels that such a scheme, rather
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
241
than antagonizing the group of laboratory
men, might meet with their approval and co-
operation. It is not at all unlikely that they
would be glad to close their individual costly
laboratories ; glad to be relieved of high rents,
large investment in equipment, technicians and
so forth. All of them, if competent, could
easily become connected with such a central
professional laboratory. The number of var-
ious examinations would increase consider-
ably and, in spite of reduced fees for each ex-
amination, their aggregate income would not
be likely to suffer. Capital for such an under-
taking could be raised either among members
of the profession, or through some rich men
whose interest in such a useful undertaking
could be aroused. It is to be expected that by
such a scheme, conceived and brought to life by
county medical societies, the profession would
advance in public esteem.
(3) High cost of hospitalization. It is a fact
that the demand for hospitalization has in the
past decade considerably increased, partly due
to better equipment of the hospitals and more
complicated methods of diagnosis, partly to
the change in living conditions of the popula-
tion. But it is also a fact that the cost of hos-
pital care has risen beyond the general rise in
other commodities. There are large new hos-
pitals where the patient, paying $5, $6 and
even $7 per day, is classified as semi-private;
meaning that the total expenses of his main-
tenance therein are not fully borne by him.
And, at that, he is charged separately for
laboratory examinations, use of operating
room, anesthesia, and so forth. If one con-
siders that on one hand all the patient gets
for his money is a bed. limited food and or-
dinary nursing, often far from adequate; and
that, on the other hand, the hospital has no
rent to pay, no interest on investment (as all
this is supplied by public funds), and no taxes,
the high cost of maintenance appears puzzling.
It might be because of a tendency of over-
expansion, recently in vogue, or due to the
fact that general hospitals are being built on
the style of luxurious first class hotels, with
large amount of space wasted, too many
richly outfitted private rooms that are often
vacant, and too large an office force. One has a
feeling that the same hospital which runs up a
yearly deficit, might, in private hands pay
dividends while rendering the same kind of
service. This high cost can hardly be ex-
plained by the number of free patients, be-
cause this number in our private hospitals is
not so large, and besides, the hospitals are
being paid for the care of indigent patients by
municipalities, counties and, in our city, by
considerable allotments from the Welfare Fed-
eration.
There is a growing tendency among hos-
pital executives to advocate “big business"
methods in hospital management. The writer
is opposed to these tendencies. He cannot see
how hospitals can be compared with industrial
productive plants or distributing agencies.
Methods in hospital management must be dif-
ferent, must be individualistic and humani-
tarian. It may be perfectly proper for a hotel
to refuse accommodations to a patron unable
to pay the fixed rates, but it is not so when
a hospital refuses admission to a patient in
need of hospital care, who cannot afford to
pay more than $3 per day, on the ground that
all the $3 beds are occupied, while there are
a number of higher-priced beds vacant. This is
an every-day occurrence and is likely to be the
source of discontent and bad feeling toward
the hospital and the profession.
One is aware of the complexity of this hos-
pital problem, [t is this complexity which is
likely to have brought about the organization
of the “Committee on Cost of Medical Care”.
It is up to the county and state societies to de-
termine whether they are willing to wait for a
report of this committee or to take the matter
in their own hands and appoint their own local
investigating committees.
And yet, with all the adjustments which are
within the power of the organized profession,
and which to a great extent are likely to allay
the existing unrest among people and various
agencies, and will increase the good-will and
respect toward the profession, one realizes
that the whole problem of sickness cannot be
easily solved. There are other aspects, requir-
ing broader public measures. Sickness will
still remain a frequent emergency with which
the average wage worker, small salaried man,
242
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
small business man, will be unable to cope if
left entirely to his own resources. Sickness al-
ways was, even with the lowest cost of medi-
cal care or with no cost at all, the greatest
factor in causing destitution and pauperism.
The principle of Health Insurance in the same
degree as it is accepted in fire insurance must
be recognized, with the important difference
that it should not be left in the hands of profit-
making agencies. The state seems to be the
logical carrier for a health insurance scheme,
and it is likewise logical to expect that the
state shall carry part of the financial burden.
Various schemes of health insurance exist
abroad, and- it is up to our Commonwealth to
work out its own plan in accord with our
economic status. It is evident that a proper
health insurance scheme will greatly change
medical practice. There would not be any
more the great prevailing demand on the medi-
cal profession to render free services. It would
cease to pauperize the people who crowd the
innumerable dispensaries. It would decrease
the demand for free beds in the hospitals, and
the profession, which will be paid for its
services by a greater number of people, will be
in a position to charge lesser fees to the rich
and middle class. Wasn’t this aspect admir-
ably brought out by Dr. Linn Emerson in the
August number of our Journal?
The writer is not an economist, and he has
no intention to go any further than to express
his faith in the principle. Does state health in-
surance necessarily imply state medicine? We
believe not. There does not seem to be suffi-
cient reason why state health insurance may
not be compatible with individualistic medi-
cine, regulated by better organized county so-
cieties. The state insurance fund might ex-
ercise its legitimate control over expenditures
through aid of these county societies.
To conclude this possibly too lengthy dis-
course, I wish to say that it was stimulated
by the aforementioned essayists. Like our edi-
tor, Dr. Reik, I am tempted to quote the
statement by Dr. McBrayer “that every unit
of our organization and every member there-
of should familiarize himself with the trend of
things that affect in any way, either for good
or for evil, the practice of medicine”. And
let us not talk generalities, which are not get-
ting us anywhere, but discuss real, every-day
conditions, even if they do affect one or other
groups of the profession. Let us be candid in
appraising values, as well as in finding faults.
The writer hopes to be forgiven for dissenting
from the others with regard to the much dis-
cussed plan of our Dr. Harris. No one will
be more happy than he if this plan will stand
a real test in any large community. And, I
wish to call the attention of our county so-
cieties to the suggested Laboratory Scheme,
which to its author, at least, looks practical and
worth the efforts necessary to its realization.
DE PROFUNDIS
By Rollo de Caen
Out of the depths have I cried unto Thee:
“Lord, hear my cry!”
The answer comes in the smile of a friend
Passing nigh.
Out of the depths have I cried unto Thee:
“Lord, still my wo!”
The answer comes in the voice of a friend,
Comforting, low.
Out of the depths have I cried unto Thee:
“Lord, heal my pain!”
The answer comes in the tears of a friend,
Sympathy’s rain.
Out of the depths have I cried unto Thee:
“Lord, make me strong!”
The hand of a friend is laid on mine,
Clasping it long.
Out of the depths have I cried unto Thee:
“Clear Thou my doubt!”
The answer comes in the faith of friends,
Encamping about.
— The Homiletic Review, New York.
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
243
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J.
Entered at the post office at Orange, N. J., as second-class matter
PUBLICATION COMMITTEE
HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J.
EDITOR:
HENRY O. REIK, M.D., F.A.C.S., Vermont Apartments, Atlantic City, N. J.
Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to
receive the paper will confer a favor by notifying the Chairman of tie Publication Committee of the fact.
NOTE. — The transaction of business will be expedited, and prompt attention secured if:
All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to
The Editor, Atlantic City, N. J.
All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements,
or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication
Committee, (address above), Newark, N. J.
CONTROL OF SPECIALISM
Repeated appearance in legislative halls of
the Act to Control Practice of Surgery and
the Surgical Specialties suggests the advisa-
bility of giving that question more serious con-
sideration than it has yet received within
our professional ranks. We were fortunate
this year, in so far as legislative course of
the Act was concerned, in having it blocked
at the very entrance to the Legislature but we
cannot count upon always having such an
interested and capable friend on guard in the
Senate, and we should not throw the whole
burden of defense upon our friends in Tren-
ton. If there exists any material abuse of
practice in the surgical field it is our duty to
ascertain the character and extent of such
abuse and to correct any discovered faults, so
that the people will have no need for recourse
to legislation.
This is by no means a local problem. It is
being considered not only in New Jersey and
neighboring states but even in foreign coun-
tries. The French Academy of Medicine
adopted last year a series of regulations quite
similar to the requirements for a surgeon’s
license set forth in the legislation then pro-
posed here. At this very moment the Royal
College of Surgeons of England is preparing a
fellowship examination to which surgeons in
Australia will shortly be submitted as part of
the plan for establishing another branch of
the College, and those candidates for fellow-
ship are expected to subscribe to a set of rules
which include the following :
“ ( 1 ) The patient, or the person legally re-
sponsible for him, must consent in the choice
made of a surgeon to perform the operation.
It is to be noted that such a consent would be
an essential factor in the successful suit by a
surgeon for the recovery of his fee.
(2) Having been selected by the patient, the
surgeon is personally responsible to him for
the operation. He is also responsible for, and
shall conduct, the postoperative treatment, ex-
cept by special arrangement with the patient.
(3) The surgeon must render his account
direct to the patient.
(4) The surgeon must not accept his fee for
an operation from the practitioner in charge of
the patient, unless the surgeon forwards a re-
ceipt for the fee received direct to the patient.
(5) If circumstances compel the surgeon to
delegate the postoperative treatment of a pa-
tient to another practitioner, the latter must
collect the fee for so doing direct from the pa-
tient. The surgeon must not pay the prac-
titioner in charge of the patient a fee for con-
ducting the postoperative treatment.
(6) Separate accounts for the assistant,
anesthetist or other necessary services must be
sent to the patient, or the surgeon must state
on his account form the exact amounts due
for these services.
(7) The assistant’s standard fee shall be
not more than one-eighth of the operation fee.
244
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
or, alternatively, nor more than 5 guineas
($25). When, owing to special circumstances,
the assitant’s fee is larger than this amount,
the assistant must render his own account on
his own account form.
(8) The anesthetist’s standard fee shall not
be more than one-eighth of the operation fee,
or alternatively, not more than 5 guineas.
When, owing to special circumstances, the an-
esthetist’s fee is larger than this amount, the
anesthetist must render his own account on
his own account form.
(9) It is desirable that the practitioner in
charge of the patient should be present at an
operation on his patient. Should he have to
travel any considerable distance for this pur-
pose, the patient must be informed before-
hand of the extra fee involved.”
It will be observed that the above rules deal
mainly with the prevention of fee-splitting ,
while the French action and the proposed New
Jersey law dealt chiefly with the qualifications
of surgeons and specialises. As reported in
the February Journal, the New York Aca-
demy of Medicine has under consideration a
plan submitted by its president, Dr. Flartwell,
for some degree of control of this matter by
special class recognition within the Academy ;
the title of “Fellowship” being reserved for
such members as can show special qualifica-
tion. Another plan, or rather, what appears
to be a step on the way toward solving quali-
fication by applying the stamp of professional
approval, appeared in the January issue of the
Journal of the Indiana State Medical Associa-
tion ; consisting in publication monthly of the
names of all state society members who are
Fellows of the American College of Surgeons,
or of the American College of Physicians, or
who hold certificates from one of the na-
tional boards of examination — those now
recognized covering ophthalmology, oto-
laryngology. and gynecology and obstetrics.
None of the plans thus far disclosed com-
pletely or even satisfactorily meets the situa-
tion. So, for the double purpose of correct-
ing any discoverable evils and of preventing
or avoiding undesirable legislation, we urge
the society to make a deeper study of com-
plaints and to formulate a definite plan of
action.
NEGOTIATING LOANS FOR MEDICAL
EXPENSES
The persistence of credit agencies in be-
seeching our endorsement of schemes for
loaning money to patients with which to con-
tract for contemplated surgical operations or
to pay for medical services previously render-
ed, in other words the application of “instal-
ment buying” to the practice of medicine, has
caused us to keep an eye open for informa-
tion bearing upon this question. None of the
schemes so far presented has seemed to us
worthy of approval ; even the best of them
have held for the practitioner no advantages
over means of collection already at his com-
mand, and seemed to hold for the patient only
another means of borrowing money to pay
for things he could not afford.
The national committee engaged in study-
ing the cost of medical care has recently issued
a pamphlet covering an investigation of “the
use of small loans for medical expenses”,
which gives us some new light on this kind
of borrowing. Among the facts deduced by
the investigation are: (1) That 28 persons
out of every 100 who borrow from small loan
companies do so because of expenditures as-
sociated with or growing out of sickness. (2)
Interest rates on such loans vary from 12% to
42% per annum. The high cost of such loans
is certainly not conducive to a lessening of the
high cost of medical care, and physicians
should not, for other good and sufficient rea-
sons, encourage the financial victimizing of
their patients by usurious interest charges.
Information was obtained from 271 loan
agencies located in 135 different cities in 21
different states; incidentally, from 29 agencies
in 23 cities in New Jersey. It is interesting
to learn that in New Jersey those who gave
“medical expenses” as the chief reason for
borrowing formed only 11% of the whole
number of borrowers, as contrasted with an
average of 28% in all the states studied ; and,
that our 11% was the lowest, and most favor-
able, score of any state examined.
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
245
LEGISLATION IN THE MAKING
As we go to press this month the General
Assembly of New Jersey, session of 1931, is
just entering upon the stage of enacting a
series of new laws. Under a new plan of pro-
cedure, tried out in some measure last year,
a date was set for terminating the “open sea-
son" for introduction of new Bills — a date
later than which no Bills could be introduced
save by unanimous consent — and legislators
took a recess of 2 weeks’ duration for study
of newly proposed measures, and to afford
citizens an opportunity to do the same. At
the session of February 9-10, a great mass of
documents was dumped into the hopper ; a
total of 672 Bills having been presented to
the Senate and House as this year’s contribu-
tion of new offerings.
In this welter of proposed laws we find the
“steady-regulars’’ designed to confer special
privileges upon osteopaths' and to create a
new group of licensed practitioners to be
known as naturopaths ; also the usual number
of provisions that would make it mandatory
upon the Board to grant special licenses to
“pets" of certain statesmen— pets who have
found it difficult to comply with the require-
ments of existing law. The legislature has
more than once rejected each of these pro-
posals, and we believe the same fate awaits
the present group.
That one of the Abell Commission Bills
which occasioned the profession some con-
cern toward the close of last year’s session — -
the proposition to amalgamate into a single
bureau 12 of the special Boards of Examina-
tion and Licensure — seems to have been
dropped ; at least, it has not yet made a re-
appearance.
IN THIS ISSUE
At the last Annual Meeting one of the most
valuable program contributions was the sym-
posium presented by representatives from the
several state departments having to do with
medical problems. Taken as a whole they
supply a comprehensive picture of medi-
cal practice as at present conducted by or
under guidance of the state ; and possibly the
alliance between the state and the profession
is closer and its effects more extensive than
many of you supposed. Commissioner Ellis’
paper is particularly illuminating; and the ex-
planations given by Director of Health Bowen
and one of his chief aides, Dr. Levy, help
materially to elucidate the development and
progress of public health work.
In our travel talk this month we have tried
to explain the British National Health Insur-
ance Law — the so-called state medicine of
Great Britain. As explained there, we are
not posing as an advocate of state medicine,
not offering even the recently proposed law
of the British Medical Association as appli-
cable to these United States, but have at-
tempted to secure and describe an honest, un-
biased report of conditions in England with
respect to this question. We do think the
time has arrived when medical societies should
carefully study the development of state medi-
cine in other countries and consider what ac-
tion the profession of this state and country
should take to prevent, or be prepared to take
to counteract, imposition of state medicine in
an aggravating form.
Next month we shall write of conditions in
France.
CORRECTIONS
In the reported proceedings of the Tristate
Medical Conference, February Journal, an er-
ror was made by the printer which may have
caused some of our readers confusion; what
should have been pages 154 and 155 are pub-
lished in reverse order. Please make that cor-
rection in your copies of the Journal ; i. e.,
renumber the pages and in some manner di-
rect attention to the fact that what was printed
on page 155 shall precede what is on page 154.
Furthermore, on page 148, near top of first
column, the center headline reading “Message
in Rehabilitation Work" should read “Mas-
sage”— etc. A mistake in spelling the word
“rehabilitation” was corrected in proof-read-
ing but in the process of resetting the type the
printer corrected the first mistake and then
made a new one.
246
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
Special Article
MEDICAL TRAVEL TALK
A Physician’s Vacation in Ireland, England
and France
Henry O. Reik, M.D.,
Atlantic City
(Continued from February Journal)
In preceding letters we promised to submit
this month some of the information picked
up during the summer regarding the National
Health Insurance Act of Great Britain. To re-
print in its entirety the original law enacted in
1911 and amendments adopted at various times
since, notably in 19 13- ’20- 22 and ’28, together
with commentaries upon the working of the
law, explanation of the necessity for changes
and the effect of such modifications, and then
to add even an abstract of the recently pro-
posed substitute, would require a great deal
of space and might result in confusing rather
than clarifying your concept of the situation.
\\ e will, therefore, endeavor to digest both
the old and the new plan and to present you
with the essential facts correlated in such man-
ner as to give a comprehensive picture of ex-
isting and prospective conditions. In order
that our statements shall be as accurate as may
be, we shall quote only from official docu-
ments : ( 1 ) The Statutes, Regulations and
orders relating to National Health Insurance,
published for the Ministry of Health, by His
Majesty’s Stationery Office, Adastral House,
Kingsway, London, 1929. (2) Medical Insur-
ance Practice, prepared by R. W. Harris and
Leonard S. Sack, and issued by the British
Medical Association for the guidance of health
insurance practitioners. We need scarcelv ex-
plain that the first mentioned book comprises
the original law and its amendments, in 133
paragraphs each of which bears marginal an-
notations of explanatory nature, and such
official regulations as have been found neces-
sary in application of the law. The second
book is of greater value for our present pur-
pose, because it constitutes an interpretation
of the law in the light of all that has happened
since its inception 19 years ago.
In September 1922, Mr. Harris, an Assist-
ant Secretary in the Ministry of Health, and
Mr. Sack, Barrister-at-Law, both of whom
had been associated with the Government’s
efforts to apply the Insurance Act and make it
workable, joined in writing this “book of ref-
erence” so that the insurance physician could
have at hand authentic answers to all ques-
tions arising in his work. A second edition,
made necessary by amendments incorporated
into the law, was published by the authors in
1924. Publication of the third edition, in
January 1929, was taken over by the British
Medical Association, for the benefit of its
many interested members, and bears the stamp
of that organization’s approval. The preface
to this most recent edition was written by the
Chairman of the Insurance Acts Committee
of the British Medical Association, Dr. H. G.
Dain, and the first paragraph reads as fol-
lows :
“It must to many have seemed amazing that so
everyday a matter as the doctoring of a person
could have produced or required such a mass of
regulations and terms of service, but the present
conditions are the outcome of experience and neces-
sity. Consideration will show that the need for
so complicated a system is brought about in the
main when the service rendered by the doctor to
the patient is provided and paid for by a third party
who is never present when the service is rendered,
and by the insistence of the medical profession on
the right of every registered medical practitioner to
go on the panel, if he wish, and on the right of
free choice by both doctor and patient. For these
fundamental principles we pay in complicated regu-
lation."
Half-submerged in that paragraph is a
phrase worthy of special attention by those
of us who have been fearing the advent of
state medicine in this country. Recall the facts
that the Association strenuously fought against
acceptance of this law and a large proportion
of its members refused at first to enroll for
service, and then note the present “insistence
of the medical profession on the right of every
registered medical practitioner to go on the
panel, if he wish”; and ponder on the changed
attitude.
At present the law is limited in application
to about 15,000,000 persons — embracing only
persons, of either sex, above 16 vr. of age em-
ployed in manual labor or in other labor for
which the remuneration is not more than £250
($12501 a year; and a small group of per-
sons who because of previous alliance with
other health insurance schemes are permitted
to hold over as “voluntary contributors” to
this plan.
The insurance benefit fund is provided
through contributions by the insured em-
ployees, their employers and the state. In the
original scheme the fund was to come — “as to
seven-ninths from contributions of the em-
ployed person and the employer, and two-
ninths from the Exchequer”, but numerous
changes have been made as necessity required
an increase of the total fund, and consequent
increase in the per capita assessment, until at
present “a sum of 13 shillings ($3.25) per an-
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
247
num is ear-marked by statute for medical
benefit (average per person), **** and “the
contribution of the Exchequer (toward this 13
shillings) is one-seventh in the case of men
and one-fifth in the case of women”. If we
study the figures for a fiscal year, which take
into consideration interest earnings, etc., it
will be seen that each 13 shillings’ item is
secured by assessing the employer for one-
third, and the insured laborer a trifle less than
one-third ; or, in simpler language, the em-
ployee secures health insurance at a cost of
approximately 4 shillings ($1).
Enforcement of the Act is under direction
of the Minister of Health, but practically all
normal negotiations with the insured are car-
ried on through “approved societies” — insur-
ance companies, as it were — with whom the
Government has contracted to look after such
details.
The benefits provided for insured persons
comprise :
(1) Medical treatment and attendance
(called “medical benefit”), including proper
and sufficient medicines and chemicals as may
be prescribed, and surgical dressings and ap-
pliances ; but does not include obstetric at-
tendance or treatment.
(2) Periodic payments while incapable of
work because of some disease or bodily or
mental disablement, for a period not exceed-
ing 26 weeks (called “sickness benefit”).
(3) In the event of disease or disablement
lasting longer than 26 weeks, payment of a
“disablement benefit” during continuance of
incapacity for work.
As will readily be seen, the above provisions
make it necessary that the attending physician
shall furnish :
( 1 ) Medical attendance and treatment such
as is expected of a general practitioner.
(2) The prescribing of proper and suffi-
cient remedies.
(3) Prescribing or supplying suitable sur-
gical dressings and appliances.
(4) Keeping of accurate records and fur-
nishing if and as required certificates of dis-
ablement or incapacity.
We may be forgiven for saying at this point
that the last mentioned requirement has been
the cause of more trouble than all the others
combined. Physicians, everywhere, just love
what in the army they called paper work. No
group of people understands better the neces-
sity for and the value of accuracy in small
things ; and no group has a greater dislike for
the task of making and preserving accurate
records.
Who mav practice? In theory, at least, this
service might have been rendered by full-time
salaried medical officers, or it could have been
entrusted to specially selected part-time gen-
eral practitioners, but, in fact, “Parliament
decided to throw this service open to the
whole medical profession and accepted the
basic principle that every qualified medical
practitioner is entitled to treat insured per-
sons”, provided that he has not been disquali-
fied by misconduct.
Any qualified medical practitioner (in ef-
fect, that means any member of the British
Medical Association in good standing) can
share in the insurance practice by merely ex-
pressing the wish and signing the roll of The
Panel, more formally called “The Medical
List”.
Here let us again pause for comment. In
confiding this work to properly qualified, li-
censed, registered physicians, and in other-
wise placing all professional matters under
control of the regular profession, Parliament
and the Health Ministry knocked the props
almost completely from under the cults, bur-
thermo re, you may have noted that the panel
doctor is only required to serve as a general
practitioner ; he is not expected or required
to act as a specialist in any branch of
medicine or surgery. In practice, that pro-
vision has helped materially to solve the prob-
lems involved in fixing a dividing line between
general and special practitioners. The insur-
ance Act provides for consultations and for
referring patients to surgeons or other special-
ists, but as it does not provide payment of
panel doctors for work out of their proper
sphere they are not tempted to perform any
operation except those required by emergency
— and small emergency operations are recog-
nized and compensated for when properly
attested.
Selection of Physician. “Every insured person is
entitled to medical treatment, within the range of
service provided, whenever and wherever required
(in Great Britain). The insurance doctors in any
area have a collective responsibility for the medical
treatment of every insured person in the area who
applies for it.’’
As previously indicated, the worker regis-
ters with and pays dues to an insurance com-
pany.— “approved society” — and receives a card
of identity, which card he takes to the physi-
cian of his own choice, and, if acceptable to
the latter, registers upon that physician’s panel.
The chosen physician is, however, entitled to
refuse to accept the applicant, and in that
event the Insurance Committee will aid the
insured person in selection of or assignment
to another physician. The only obligatory 1 ac-
ceptance of a patient deals with the rendition
248
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
of service in an emergency. There are elabor-
ate provisions covering every possible exigency
that may arise to disturb the relations of
physicians to patients, and in dealing with
such problems, as with all other problems as-
sociated with application of this law, the medi-
cal profession is adequately represented on
the committe of adjustment.
Limited Size of Lists. “As a limit to the number
of insured persons, well and ill, for whose treatment
an insurance doctor can undertake responsibility,
a maximum of 2500 insured persons is fixed and no
single-handed insurance doctor may ordinarily have
more than this number on his list. * * * Where
2 or more doctors carry on a practice in partner-
ship, any one of the partners may have up to 3000
names on his list, but the average of the lists of
all the partners must not exceed 2500.”
Keep in mind that the above mentioned
figures do not mean 2500 patients; they only
mean 2500 persons any of whom may become
patients at some time. Save during epidemics,
there is rarely more than 1% of such listed
persons ill at any given time.
Payment for Services. Various methods of
payment were considered — such as payment
by salary, payment for number of cases treated,
payment by a fee system according to char-
acter of services rendered — but it was finally
decided to pay on a per capita basis of the
insured population, well and ill. So, at the
beginning of each year the department sets
aside a specific fund based upon an estimate
by the Government Actuary of the number of
insured persons multiplied by the agreed capi-
tation fee. The gross fund available for medi-
cal service is then apportioned among the
counties or boroughs, according to respective
proportions of insured persons, and allotted
to physicians in accordance with the relative
number of persons on the list of each. There
is also an apportionment to pharmacists, to
cover prescriptions filled and appliances fur-
nished, and an additional fund to cover medi-
cines and supplies furnished by physicians in
areas where pharmacies are not available. The
distance a physician may have to travel to care
for a patient is also taken into consideration
and he receives mileage for all calls beyond a
certain distance from his office.
It might be expected that incomes from this
source would vary considerably, and we as-
sume that they do, but we were told that the
average income from this insurance work in
manufacturing districts, where laborers are
naturally congregated in largest numbers, is
approximately £1000 ($5000) and that in-
comes of £1500 are not uncommon. We can-
not vouch for the accuracy of those figures ;
they were proffered, in fact, as estimates, or
guesses, but by individuals who were or had
been in positions that enabled them to make a
“reasonable” guess. We can, however, offer
some figures from a reliable source and ap-
plicable to the entire country.
The Eleventh Annual Report of the Min-
istry of Health, covering the year 1929, shows
that there were 14,000 physicians on the panel,
and that they received the sum of $31,250,-
000 in respect of their duties of attending and
treating insured persons ; the insurance roll for
that year numbering a little over 14,000,000.
Those figures would indicate an average of
$2232 for each panel physician in the entire
country ; not a bad average income from one
single line of practice. In addition, the treas-
ury reports, for the same period of time:
"About $1,000,000 was paid to country doctors on
account of mileage, another $1,000,000 was paid to
doctors for medicines and appliances supplied by
them as part of emergency treatment or dispensed
in country districts, and $50,000 was set aside to
enable country doctors to attend courses of post-
graduate study and to provide them with other de-
sirable facilities (maintenance of telephones, motor
cars, branch surgeries, or reasonable vacations).”
Some details of service. When a physician
signifies his willingness to register on the
“Medical List”, for health insurance service,
he receives along with notice that he has been
enrolled a conv of the List of Insurance Phar-
macies, a supplv of prescription blanks, record
cards, certificates of illness or incapacity, and
other regular forms.
The general standard of treatment required
is that which one would observe in his private
practice as a general practitioner.
Every formal complaint, or any other
formal question arising between a physician
and an insured person, is required to be in-
vestigated by a body composed of an equal
number of medical men and of insured per-
sons’ representatives, with an independent
chairman — the Medical Service Subcommittee
of the Insurance Committee. There is a sub-
sequent right of appeal to the Minister.
In complaint cases an insured person’s Ap-
proved Society may be permitted to assist him
in the presentation of his case; the Society
itself may be the complainant in certification
cases ; but, apart from this, and excepting cer-
tain details of certification procedure, you
will find that your only relations with Ap-
proved Societies are those of an informal na-
ture in which the officials communicate with
you on behalf of members. Such informal
communications are all to the good— partic-
ularly where an illiterate member is concerned
— if on both sides it is recognized that the
communications have no official footing.
For purposes of local administration of
Medical Benefit, each country is divided into
areas, one for every county (in Scotland,
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
249
areas are amalgamated in 2 or 3 instances) and
one for every county borough, and in each
area there is set up an Insurance Committee,
responsible to the Minister, for the adminis-
tration of medical benefit within its area.
There are also set up in each area: a Local
Medical Committee, representative of doctors
generally who are resident in the area ; and
a Panel Committee, representative of the in-
surance doctors who are under agreement with
the Insurance Committee.
In his relation to insurance doctors, the
Minister is placed in a somewhat unusual
position. While he is responsible for the
spending of public money on the administra-
tion of medical benefit, he has not the cus-
tomary powers of selecting the persons by
whom the work is to be carried out — every
qualified doctor having, as already explained,
the right to treat insured persons.
The Minister, is, however, entrusted with
the responsibility for the issue from time to
time of the Regulations, etc., which define the
insurance practitioner’s Terms of Service. He
must also, in view of his responsibility to Par-
liament, have some check on the way in which
these doctors carry out their obligations. But
the Regulations afford evidence that the Min-
ister in the exercise of his powers under the
Acts is relying more and more on cooperation
of the medical profession, especially where
professional questions or professional conduct
are at issue.
In this connection his main concern must
be that the committee coming to discuss mat-
ters with him must (1) have the necessary
mandate, and (2) if undertakings are given,
be in a position to secure that they are carried
out. The body which is recognized by the
Minister as the representative body is the In-
surance Acts Committee of the British Medi--
cal Association, and all questions affecting re-
muneration or other Terms of Service for in-
surance doctors, have always been made the
subject of consultation with this representa-
tive body, and Ministerial undertakings have
been given that this course will continue to be
pursued.
Panel Committees are required by the Na-
tional Health Insurance Act to be set up, and
Insurance Committees are directed to ascertain
through these bodies the opinions and wishes
of insurance doctors, wherever these are re-
quired to be ascertained by the Act or the
Regulations.
The Panel Committee can require that the
Medical Service Subcommittee shall investi-
gate any question relating to the administration
of Medical Benefit or to the discharge by an
insurance doctor of his duties. It has also
the duty of adjudicating in cases where there
is prima facie evidence of extravagant pre-
scribing by a doctor.
The scheme of National Health Insurance
does not, it will be seen, provide for “specialist
services”, i.e., services which are ordinarily
beyond the skill or experience of general prac-
titioners. Questions of importance, and often
of no little difficulty, may, therefore, arise as
to whether a particular operation or service
which an insured person admittedly required
falls within the definition of general prac-
titioner treatment quoted above.
The Regulations provide that, where a
question of this nature arises, it is to be re-
ferred to the Local Medical Committee, and
if that Committee and the Insurance Com-
mittee— on considering the Local Medical
Committee’s report — fail to agree, it is to be
submitted for decision to 3 Referees, appoint-
ed by the Minister, 2 of whom must be doc-
tors, the third being a barrister or solicitor in
actual practice.
Emergency Treatment. In case of an emer-
gency the doctor is required to render what-
ever services are in the best interests of the
patient, having regard to the circumstances.
In other words, the test must be solely what
treatment, within his capacity, the patient ur-
gently requires. Thus, cases of great urgency
mav arise, more frequently in country dis-
tricts, “where the risk to the patient, through
your undertaking an operation which, in other
circumstances, would better be left to a
specialist, is less than the risk entailed by de-
lay”.
The general capitation fee, paid for the
treatment of insured persons in town and coun-
try alike, covers professional services and
practice expenses. It therefore includes pay-
ment for a certain amount of traveling. Doc-
tors who practice among insured persons in
rural and semi-rural areas receive an extra
payment in connection with work done (1)
beyond 2 miles from the doctor’s residence or
main surgery, and (2) in districts which pre-
sent exceptional traveling difficulties. This
extra payment is one which takes account both
of the time occupied in traveling and the cost
of traveling.
Insurance premiums are paid to the doctors
in the Insurance Service for every insured
person in the country, well and ill, and the
remuneration of every practitioner is provided
for in the Distribution Scheme for the area in
which he practices. “Accordingly, the Regula-
tions provide that you must not demand or
accept any other payment for giving treatment,
within the range of service laid down by the
Terms of Service, to any insured person who
is on your list, or who represents to you that
250
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
lie is an insured person except by way of
deposit, in cases of doubt.”
Criticism of existing plan. As already
stated, in the beginning, this law was strongly
opposed by the medical profession. Nearly all
physicians looked upon it as an unwarranted
interference with their legally established pro-
fessional and business rights, and many de-
nounced the general plan as a socialistic ex-
periment fore-doomed to failure. Prediction
was made that if it should happen to succeed
to a recognizable degree it would, nevertheless,
prove detrimental to the public and degrading
to participating physicians; these dire prophe-
cies being based upon the fear, or expectation,
that the service rendered could not or would
not be up to standard, and that through such
a lowering of professional service physicians
would themselves deteriorate. There was even
talk of a “strike” — of medical men refusing
to have anything to do with this new form of
“contract practice”.
Well, like many other horrors, these were
disposed of with less difficulty than had been
anticipated. Sober second thought must have
convinced many objectors that (1) the oft-
repeated experiment of holding back the tides
with a broom had never yet succeeded, and
(2) that their fears of professional deteriora-
tion— in practice and in reflex effect — were
not flattering to themselves. At any rate, 14,-
000 physicians in England, Scotland and Wales
are now “on the panel”, and our inquiry as
to how the organized profession now feels
about it brought the response that: “If sub-
mitted to the British Medical Association for
a vote, the question of supporting the present
health insurance law or having it abolished
would bring out a tremendous majority in
favor of existing conditions, because it has
benefited both public and the profession.”
In recent years criticism has taken the form
mainly of charges that some bad results have
accrued, or may yet develop. For instance:
excessive prescribing of extravagantly expen-
sive drugs; malingering, encouraged by doc-
tors who may be too easily induced to sign
certificates of disability or incapacitation ;
repetition of the fear that the profession will
ultimately suffer a slump in scientific output
as an indirect result of slothfulness that some
consider a natural development among those
engaged in contract practice or institutional
work.
We sought factual information upon those
points. There have been many instances of
malingering and some cases of certificate falsi-
fication and of improper prescribing. There
is some evidence that malingering exists among
the insured ( especially among married women
under 45 years of age) to a greater extent
than among people of the same class in other
comparable countries or in Great Britain prior
to enactment of the insurance law. Advocates
of the insurance scheme are, however, quick
to point out that all the above mentioned com-
plaints and objections are criticisms of human
nature rather than of the law; that the bad re-
sults, where proved, are due to moral defects
and obliquities on the part of some patients or
some physicians, and do not constitute any
more serious criticism of this law than do
evasions of other laws justify their condemna-
tion.
Inquiry through medical channels elicits, as
might be anticipated, the prompt denial of pro-
fessional abuses on any large scale ; admit-
ting that a few panel physicians have been
guilty of aiding and abetting malingerers, and
of abusing prescription privileges, it is claim-
ed that the total number of such transgressors
constitutes but a small percentage of the whole
number of panel doctors. Honest panel physi-
cians also point out the fact that moral delin-
quency is not an unknown occurrence among
physicians engaged solely in private practice.
In so far as the medical profession is con-
cerned we may safely conclude that the per-
centage of wicked physicians is not higher
among those engaged in state medicine than
among those occupied with private practice
alone ; that the number and the percentage of
wicked workers in either group is very small;
and that such abuses of the law as have grown
out of too great complacency on the part of
physicians — •'whether to favor patients or
pharmacists — are reflections upon human
character rather than justifiable criticisms of
the law.
There is apparently mighty little complaint
in England as to the quality of service render-
ed by panel doctors; and that is not only what
we would expect but speaks well for the honor
of our profession. The people appear to be
satisfied ; the Government seems to be satis-
fied ; in fact, the opinion seems to be gen-
eral that the class of people insured is now
better cared for medically than ever before,
and that physicians are now paid for services
which formerly they were compelled to ren-
der mostly on a charity basis.
The intimation that physicians, as a group,
will render a lower grade of service to panel
than to private patients, and the fear that any
considerable number of physicians will lose in-
terest in medical science just because they
happen to be engaged in what somebody has
called wholesale, as compared to retail, prac-
tice, are propositions that seem to us unworthy
of discussion ; indeed, they can hardly be dis-
cussed without first accepting fundamentally
the implication that the medical profession is
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
251
composed largely, if not in the main, of
greedy, grasping, reward-seeking individuals
who base the quality of their service upon the
amount of pay to be derived and who have no
other interest than a selfish financial one in
the progressive development of themselves
and their science — and those are allegations
that all history denies.
Control of excessive or extravagant pre-
scribing, and of improper certification of ill-
ness or incapacity to work, is to a certain ex-
tent in the hands of our profession’s represen-
tatives upon the various committees executing
the law and in the British Medical Associa-
tion.
The extent of malingering is in a manner
indicated in the Health Ministry’s Annual Re-
port previously referred to :
“The number of references to regional medical
officers for advice as to incapacity for work in 1929
was 410,903 (408,934 from approved societies, 1079
from insurance doctors, and 890 from insurance
committees). Of these references 133,707 (or 33%)
related to men and 277,196 (or 67%) to women.
The number of persons actually examined on ‘in-
capacity references was , 211, 634. The number who
declared themselves off the funds before the date
fixed for examination was 109,661, and 89,750 failed
to attend for other reasons. Of the persons ex-
amined 143,898 were reported as incapable and 67,-
736 as not incapable of work.”
The above figures show that practically one-
half (49%) of all malingerers who carried
their claims to the point of demanding a certi-
ficate of incapacity were eliminated by the ex-
pedient of requiring submission of the ques-
tion to a referee. Of the number submitting
to reference examination, approximately two-
thirds were found to be actually incapacitated
and one-third to be malingerers ; which, in
turn, indicates that only about 35% of the
original claimants was sustained, and 65%
was weeded out.
Before leaving this portion of our letter —
this summary of such facts as we were able to
glean from a cursory study of the law oper-
ating in Great Britain — let us say emphatically
that we have not attempted nor meant to ad-
vocate, or argue in favor of, establishment of
so-called state medicine here. We have tried
to ascertain the facts concerning national
health insurance in Great Britain and to pre-
sent those facts in logical sequence and in an
unprejudiced manner; at the same time pre-
senting such answers as were vouchsafed us
with reference to criticisms. We confess to
having been aggravated many times by state-
ments published in various American medical
journals — statements which we felt certain
were misrepresentations, or unjust charges, or
unfair deductions and inferences — and it is
possible that we have exhibited the reaction
effect of such an influence. It is difficult, for us
at least, to present any debatable question with
absolutely perfect impartiality. Herein, we
have tried to present both the facts and the
explanations without bias, even when em-
phasis seemed necessary, but we have been
conscious, too, of a feeling that the facts, in
their strongest form, had best be faced. If
there is either a threat or a natural prospect of
state medicine coming soon for consideration
here in New Jersey, or in any of these United
States, we cannot afford to blink the facts;
and in our humble opinion the wisest prepara-
tion for dealing with the problem consists in
first learning all we can about the experiences
of other countries.
Stand of ti-ie British Medical Associa-
tion as Regards the Future
Whatever opposition the British National
Health Insurance Act encountered in the begin-
ning, and whatever criticism may be directed
at it now, it is a noteworthy fact that the Brit-
ish Medical Association has recently submitted
to the Government a proposal to extend that
law — with slight modifications — to embrace the
entire populace and to cover medical practice
in all its varied aspects. The proposed plan in-
cludes preventive as well as curative medical
service ; treatment by specialists as well as by
general practitioners ; hospitalization and con-
valescent provisions as necessary ; auxiliary
service in the line of radiography, electro-
therapy, physiotherapy, hydrotherapy and
massage ; mental disease institutions and ma-
ternity homes; infant welfare and school in-
spection ; coordination with public health de-
partments ; and all to be available to the in-
digent as well as to those who can pay in part
or in full for health insurance. It is a thor-
oughly comprehensive scheme. And this is
the result of 19 years of observation, study
and experience on the part of the physicians
of Great Britain. If adopted, the plan would
not entirely destroy private practice ; while all
physicians would be eligible to state practice,
none would be forced to take part, and persons
desiring to employ private, nonparticipating,
practitioners — general or special — would be at
liberty to follow their own bent.
The single modification of the existing law
asked for, in so far as we have discovered, is
that provision shall be made for direct contact
between patient and physician instead of ne-
gotiations through any third party — meaning
the “approved society”.
“That the interposition of any third party
between the doctor and the patient, so far as
actual medical attendance is concerned, shall
be as limited as possible. In the first place,
t1- 2 relations between doctor and patient are
252
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
so intimate that both doctor and patient right-
lv resent any outside interference. Such in-
terference is bad for the doctor and worse for
the patient. It is bad for the doctor because
his whole training and the traditions of his
profession tend to foster the idea of personal
responsibility, and this can be undermined
only at the risk of rendering the doctor less
efficient. It is worse for the patient, because,
ex hypothesi, he or she is a sick person whose
cure depends very largely on complete con-
fidence in the doctor, and this confidence is
built up to a great extent on psychologic fac-
tors which are disturbed by the intrusion of
outside agencies. The Association pleads on
behalf of the poorer section of the community
that they should have the same consideration
in this matter as is demanded as a matter of
course by the more wealthy sections of the
community. There is no more reason why
any third party should come between the pa-
tient and his medical adviser than between the
individual and his spiritual adviser.
The experience gained from the National
Health Insurance system has shown that the
interests of the public are best served in any
organized medical service by putting as much
responsibilty as possible on the doctors giving
the service — responsibility, that is, for the
quality of the service and for its smooth work-
ing. There are no severer critics of delinquent
doctors than a body of their own colleagues
invested with the control of purely profes-
sional affairs. And there is no surer and
easier way of securing an efficient service than
to enlist the active interest of those whose
reputation as a profession is involved in the
way in which the-” exercise collective respon-
sibility entrusted to them.”
In sponsoring the proposition, the Associa-
tion further says:
“During the past 20 years the attention of the
public has been directed more than ever before to
the subject of ‘The Health of the People.’ Many
factors have led to this increase of attention. The
systematic medical inspection and treatment of
school children; the National Health Insurance
system and the varied experience gained from it,
including the striking evidence as to the loss of
millions of weeks of work in a year owing to ill
health among the insured population; the establish-
ment and the activities of the Ministry of Health;
the devastating influenza epidemics; the experience
gained from the operations of the maternity and
child welfare schemes of the local authorities; pub-
lic inquiries into different aspects of the question,
such as the reports of the Consultative Medical
Councils in 1920, the Report of the Royal Com-
mission on National Health Insurance in 1926, and,
more recently, the inquiries into the subject of
maternal mortality; the increasing interest in the
subject taken by the press — all these have combined
to make the problem of how best to promote the
health of the people one of che most interesting
and pressing public questions of the day.
The British Medical Association, as a body repre-
senting the great majority of doctors in this coun-
try and in the British Empire, has not been inac-
tive all this time. It has indeed, been busily en-
gaged in studying in detail various arpects of the
question, with the object, first, of eliciting the views
of the main body of the profession and then of
focusing those views into practical schemes. Many
of these sectional schemes have been placed before
the Government; some, such as the recent plan for
dealing with maternal mortality, have been given
wide publicity. The Association now feels itself to
be in a position to piece these plans together and
to submit to the public a coherent and inclusive
scheme of medical service based on a few simple
basic principles. This scheme would, it is believed,
provide the community with a service available for
every class of the population, comprehensive enough
to cover the whole field of preventive and curative
medicine, and sufficiently elastic to permit of fur-
ther developments as these may be found neces-
sary. As the Association said in a pamphlet pub-
lished in 1918, stating its views as to the way the
new Ministry of Health should work: ‘The system
of medical provision which the Ministry of Health
should seek to establish is one which would give to
all who need it every kind of treatment necessary
for the cure or alleviation of disease, and would
utilize for this purpose every class of medical prac-
titioner.’
A comparison of the National Health Insurance
system of this country with those of other coun-
tries shows that the quality of the service given
here is in many ways superior to that of many
other countries, and certainly there is a more con-
tented service, mainly because the management and
control of the purely professional side of the work
and the disciplining of the doctors connected with
it have been increasingly entrusted to the profession
itself.”
(To be continued.)
Medical Ethics
THE PHYSICIAN IN HOLY WRIT
John Hammond Bradshaw, M.D., F.A.C.S.,
Orange, N. J.
Every book dealer will tell you that the
Bible for many years has been the “best
seller ’. To be mentioned over a score of
times, in different places, in such a work, and
in a generally complimentary way, is an ac-
complishment no profession other than medi-
cine has achieved. Without entering into the
subject of inspiration of the Scriptures, we
know that they are classified by scholars as be-
longing to the world’s best and oldest litera-
ture. The authorship and the first allusion in
the Bible to a physician dates back, we may
safely say, 10 centuries before Christ. This is
found in Genesis 50:11, “* * * and the physi-
cians embalmed Israel.” This is not mentioned
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
253
alone because of its antiquity, as 20 centuries
before this physicians were known in Egypt.
The Bible was an unwritten book at the
time of Esculapius. It is gratifying to our
pride to be told that Esculapius was the son
of Apollo and that Homer mentions the fact
that 2 of hi. 3 sons were physicians in the Greek
Army at the Siege of Troy, for we like to
think of Esculapius as the head of our clan.
Of course Hippocrates was a “modern” by
comparison.
Aside from these reflections, it is inter-
esting now to go back to the Bible.
II Chronicles 16 \12 : “And Asa in this thirty
and ninth year of his reign was diseased in
his feet, until his disease was exceeding great:
yet in his disease he sought not to the Lord
but to the physicians.”-
We are naturally elated at the above passage
until we are knocked flat by:
Job 13:4: “But ye are forgers of lies, ye
are all physicians of no value.”
Job, you know, was not himself when he
said this ; he not only had a most prolific crop
of boils, but had been through a stock-market
crash. When his friends sweetly told him
this was all because the Lord loved him so
much, it was more than he could stand, and
his doctor’s head was the nearest within
reach.
Now when we come to
leremiah 8:22: “Is there no balm in Gil-
ead : is there no physician there ? Why then
is not the health of the daughter of my peo-
ple recovered?” We know that Jeremiah was
growing old. Many a modern, and not very
old at that, has raised his voice and reached
out his hand for some “balm in Gilead”. It
is the cry of the world, and antedates even
Jeremiah.
There may be other references to physi-
cians in the Old Testament, but the writer has
overlooked them.
Our Lord mentions physicians many times.
Our calling him “The Great Physician” con-
fers honor upon ourselves.
Matthew 9:12: “But when Jesus heard
that, he said unto them, They that be whole
need not a physician, but they that are sick.”
The philosophic truth of this statement being
so apparent, we aie quite likely to miss its ab-
solute profundity.
Here is a passage especially built for the
gynecologists :
Mark 5 : 25-26 : “And a certain woman,
which had an issue of blood 12 years,
“And had suffered many things of many
physicians, and had spent all that she had,
and was nothing bettered, but rather grew
worse. . .”
But this does not refer to modern times or
modern physicians, although we must admit
that a certain part of this passage is a little
pointed.
Here is an interesting verse:
Luke 4:23: “And he said unto them, Ye
will surely say unto me this proverb, Physi-
cian, heal thyself : whatsoever we have heard
done in Capernaum, do also here in thy coun-
try.”
It would be a good thing if we all could
take this verse to heart. The trouble is, how- .
ever, that we do not think zve need to be
healed!
Here is a passage so often quoted, it is good
to know its source:
Colossians 4:14: “Luke, the beloved physi-
cian, and Demas, greet you.”
It is well to close this short article with a
few verses from Ecclesiasticus 38, the poetic
beauty of which is acknowledged by all.
Ecclesiasticus 38: 1. Honour the physician
for the need thou hast of him : for the most
High hath created him.
2. For all healing is from God, and he
shall receive gifts of the king.
3. The skill of the physician shall lift up
his head, and in the sight of great men he
shall be praised.
4. The most High hath created medicines
out of the earth, and a wise man will not
abhor them.
5. Was not bitter water made sweet with
wood ?
6. The virtue of these things is come to
the knowledge of men, and the most High
hath given knowledge to men, that he may
be honored in his wonders.
7. By these he shall cure and shall allay
their pains, and of these the apothecary shall
make sweet confections, and shall make up
ointments of health, and of his works there
shall be no end.
8. For the peace of God is over all the face
of the earth.
9. My son, in thy sickness neglect not thy-
self * * *.
11. * * * then give place to the physician.
12. For the Lord created him: and let him
not depart from thee, for his works are neces-
sary.
13. For there is a time when thou must
fall into their hands:
14. And they shall beseech the Lord, that
he would prosper what they give for ease and
remedy * * *.
254
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
Esthetics
APPRECIATION OF GOOD MUSIC
America’s Orchestra Abroad
(Editorial in N. Y. Herald-Tribune, June 5, 1930)
It was Nietzsche, that mystic realist, who
declaied, with an audacity which the wise will
not too hastily rebuke, that “we have our
highest dignity as works of art, since it is only
as esthetic phenomena that existence and the
"oi Id ai e eternally justified . Not many
Europeans have been willing to credit mod-
ern American civilization with the distinction
of illustrating that profound truth. Ameri-
cans, indeed, have somewhat uneasily sus-
pected that their civilization is misprized by
Europeans chiefly because of its supposed em-
phasis upon other things than the dignity and
beauty of life.
I his estimate of the measure of American
enlightenment may have been subjected to a
process of revision in the minds of thought-
ful foreigners by consideration of the remark-
able European tour which the Philharmonic
Symphony Oichestra, of New York, under
the direction of Arturo Toscanini, has just
concluded. That tour, which carried the old-
est of American orchestras and its illustrious
conductor over the length and breadth of the
Continent to a resounding finale in London,
has been made to an accompaniment of ponu-
lar and critical acclaim unprecedented in the
history of musical tournees accomplished with-
out benefit of jazz bands, prima donnas, 01-
tenors excitingly equipped with high Cs. For
the Philharmonic Symphony’s tour, let it be
remembered, placed no dependence upon sen-
sational appeal. Ihere was nothing sen-
sational about it save musical excellence. The
attraction , as professional showmen would
call it, was merely an orchestra of consum-
mate quality, playing standard concert works,
under a conductor who is the personification
of esthetic simplicity, sincerity and high-mind-
edness.
And what hoped-for recompense can have
been in the minds of those reckless American
Maecenases who sponsored the formidable un-
dertaking? Surely nothing more alluring than
the certainty of being out of pocket some
hundreds of thousands of dollars; nothing
more tangibly rewarding than the possibility
of suggesting to an Old World racked and
discordant that in place of those “dark say-
ings in a thousand tongues” which have long
confused it, the New World was prepared to
speak to it in the tongue of an ideal confra-
ternity— in that transcendent form of human
utterance which is essentially, as one of the
greatest of music-makers knew and said,
only a means by which one may talk with
one’s fellows”.
Collateral Reading
ON AN ANTHOLOGY OF CHESTNUTS
By the Shop Philosopher
(The Kalends of The Williams & Wilkins Co.)
Insufficient attention has been given by the
literati to the lowly chestnut. It is too hastily
dismissed as a trivial and unworthy form of
literary expression, the mere plaything of
raconteurs, particularly those of small skill
who nevertheless view what skill they have
with complacence, or of desperate editors of
the scissor variety, the exigencies of whose
office compels them to leave no glaring hiatus
in their columns. The chestnut is good only
for a passing smile, a quick guffaw — that is
the casual view ; a view I venture to believe,
which offers opportunity for revision upward.
For observe you this : the chestnut is a true
exemplar of folk-lore ; folk-lore in the mak-
ing. It is impossible to trace authorship.
Chestnuts spring full panoplied from some
mysterious splitting of the rocks. They emerge
1 rom the hodge-podge of hurrying human
atoms, particles thrown off from the boiling pot
of social interactions, products not of one im-
agination but of many, having phvlogenesis
rather than ontogenesis. And while by far
the greater portion of this spontaneous ex-
ciement must of necessity be wholly dross, a
modicum of precious metal is also found.
Now being distilled of human life itself, it
follows that the chestnut (when it rises above
mere wise-cracking, when it is genuine and
not an imitation strained after by one under
the compulsion of filling a minute of time or
an inch of space) at the very least must cap-
ture some tidbit of human nature; and at the
most may come close to a sublime summation
of the whole of it. For so-called nonsense is
tar more likely to be profound than are the
gaunt vaporings of those with the presumption
to match wits with the infinite. So, I hope
that some scholar, with the requisite balance
of scientific thoroughness and poetic intuition,
will give the world an anthology of chestnuts.
It is a far more reasonable undertaking and
far more likely to be fruitful than Dr. Wil-
stach’s compilation of metaphors.
It is unnecessary to say that the anthology
must represent something other than one in-
dividual s idea of what is funny. Imprimis
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
255
the stories must be chestnuts. The good story,
new last week, may not have staying qualities.
Each must demonstrate its validity by its vi-
tality. For that vitality demonstrates that at
least the anecdote has found a responsive
chord in many bosoms ; the presumption is
raised that it belongs to the warp and woof of
the human fabric. That presumption must be
tested against the compiler’s intuitions and ex-
perience ; for the carefully selected chestnut
must have the human quality. Then it must
have subtlety and the flavor of the epigram.
And finally, of course, it must have true ele-
r.: jnts of humor — indirection, incongruity,
surprise or any like factor which titillates the
risibilities.
As a beginning, hardly more than a hint, a
few candidates for admission are appended.
The teacher picked on Johnny to demand,
“What is the shape of the earth?”
“Round”, said Johnny promptly.
“How do you know?” — explosively,
“Oh, all right, it’s square then.”
Hay the tribe of Johnny increase! And may
the tribe of those wretches who forever are
challenging our faiths, opinions and prefer-
ences, who forever are scheming to “sell us
the idea”, who forever are laying traps for
us, causing us to commit ourselves that they
may smackingly show us how mistaken we
are, burn forever in a specially constructed
hell where they will be slowly argued, debated
and talked to a crisp !
Zeke was a country boy, and ambitious. He
decided to study law. Preliminaries arranged,
he left home on a Monday. He returned the
following Friday.
“ ’Lo, Zeke”, an acquaintance hailed, “How
do you like the law?”
“Don’t like it” said Zeke positively. “I’m
sorry now I learnt it.”
This is a study in intonation. The night be-
fore an engagement the Irish sergeant en-
deavored to inspire his men. He explained
what was to take place. Then ensued this
colloquy :
“Bhoys, will yez fight or will yez run?”
“We will !”
“Will what?”
“Will not?”
“That’s the spirit, bhoys ; I knew yez
would.”
The eccentricity of the inebriated is a fruit-
ful source of chestnuts. Few indeed however
have the superb balance of this one:
Two are seated in the smoking compart-
ment of a Pullman car. Says one, “What
time is it?”
The other gropes shakily into a waistcoat
pocket, discovers his watch, consults it pains-
takingly, and announces at length, “ ’S Thurs-
day.”
“Y’ don’t say!” returns the First Inebriate
agitato. “I’ll have to leave you. ’S where I get
off.”
Speaking of potations, this is the choicest
example of morning-after story that has come
to my knowledge :
The hero wakens in a state of utter physical
and mental disrepair, but at least in familiar
surroundings. It is his own room and his
pet kitten is meandering across the floor.
“Great Scott, cat”, moans the sufferer,
“don’t stamp your feet so!”
That, my friends, is some headache.
And I love the absent-minded professor
who scratched his pancake and poured syrup
down his neck.
In the days when the genus taxicab was
not so conspicuously marked as at present, a
man emerged from a building on lower Broad-
way, and finding a car at the curb with a
driver, he got into it and directed : “Grand
Central Station.”
Now it chanced that the car was not for
hire ; but the driver, having nothing better
to do, fell into the role so unexpectedly assign-
ed him and drove his fare in accord with the
directions. Arrived at the station the fare
said, “What’s the damage?”
“Twenty-five cents.”
“What? Making a mistake, aren't you?”
“No, sir. That’s all we ever get for this
trip.”
“And that dirty bum yesterday soaked me
2 bucks !”
It would take a lengthy essay to elucidate
the human nature in that.
The proud owner of an ancestral “place”
near London was showing a visitor about. In
due course they came to the family portraits.
“My great uncle” said the host standing
before a canvas. And added in that tone of
voice which demands that the auditor be awe-
struck and break into wordless exclaimings —
“Lost a leg at Waterloo.”
The Visitor: “Beastly place, Waterloo. Lost
me golf-clubs there last week.”
It is said that President Lincoln in the first
days of his term of office when he was tor-
tured with a pertinacious horde of office-
seekers, was especially annoyed by 3 par-
ticularly importunate ones, who always came
to him in a group. Standing one day before
a window which commanded a view of the
street below, he turned to a vis-a-vis and told
this story :
“When I was a boy in school the reading
lesson was carried forward by using the Bible
256
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
us a \ chicle. I he practice was for each mem-
ber of the class to read a verse in turn.
One day we read the story of the burning
fiery furnace from the Book of Daniel. To
little Ebenezer fell the verse in which first
occurred the names of Shadrach, Meshech and
Abednego. Eb stumbled on Shadrach, was
staggered by Meshech and fell entirely to
pieces on Abednego. He was reprimanded
by the teacher and promised a spat with a
ruler unless he improved.
The reading proceeded, almost all the way
around the class again. Suddenly Ebenezer
broke into noisy tears. The reading was in-
terrupted while the teacher endeavored to as-
certain the cause of Eb’s lament. Eb pointed
to the verse which would, by rotation, fall to
him. It contained the fateful names again.”
The President paused and called his com-
panion to the window indicating the approach
of the particularly unwelcome visitors.
“What Eb said then is what I say now”,
Mr. Lincoln continued, “Here come them same
damn 3 fellers.”
One of the compensations of the Great War
was the number of excellent tales it produced.
There was the better ’ole story, as a classic
instance, which Bruce Bairnsfather has made
immortal. It is certainly no better, however,
and I think not so deliciously subtle as the
following: '
A company of Tommies was detailed to
guard a certain road and ambush a German
patrol which was confidently expected. The in-
structions were to capture the patrol if pos-
sible, to scatter it and disintegrate it as a second
choice, but if necessary to annihilate it. The
Tommies in general regarded the last alterna-
tive as the most certain to accomplish the re-
quired end, and set themselves in array ac-
cordingly.
Midnight came and past. One o’clock. Two.
I he patrol was long hours overdue. Three
o'clock came; then 4 and still they waited.
Finally, a voice, filled with concern, was waft-
ed through the inky darkness:
“I ’ope as ow nothin’ ’as ’appened to the
beggars !”
And that reminds me. The surviving con-
tingent of the G. A. R. in a western town
planned and carried out a successful celebra-
tion. It was a large and noteworthy affair and
the editor of the local paper produced a special
edition in honor of it.
On publication he was horrified to discover
that in a fervid and sentimental editorial on
which he had expended his most flowery rhet-
oric an egregious typographic mischance had
caused him to allude to “the battle-scored
veterans”.
Mortified beyond measure he took firm ac-
tion to recover every copy of the luckless
edition. He sent out boys to canvass the en-
tire community, extending their activities into
the neighboring country for miles around. He
recovered other copies by mail. They became
precious and for some he paid as much as a
dollar apiece. He ceased not until careful
check gave him assurance, as nearly positive
as possible, that every copy had been restored
and destroyed.
Meanwhile, though type had been remelted, ;
he set up a corrected edition in its entirety.
Extraordinary care was taken. Proof was j
carefully read at every stage of production.
In particular the editor in person certified ]
with each reading that the omitted r which
caused all the trouble was in its place.
At length the presses were allowed to turn
and they turned to some purpose. Once again
the special was distributed far and wide. And
with a sigh of satisfaction, with the sense of
high duty nobly performed, the editor opened
his own copy for a loving look. Especially did
he look for that unfortunate r. Had anything,
at the last moment happened? No, thank God!
It was in place !
The line now read, “bottle-scarred” .
The Absent Minded Professor
This is a true story. Moreover it has a
moral. If you smile, don’t do it with self-as-
surance. Any one of us may be next.
An eminent scientist wrote us that he was
constantly discovering, by mere chance, that
we had published certain books ; he mention-
ed specifically a book — call it A — which he
said should have been announced from the
housetops. Yet he had to find out who pub-
lished it by writing to a colleague. He ordered
2 copies of A as well as 2 copies of B,
another book he was much interested in and
had discovered only casually. B was not our
publication. It was, of course, a polite letter
but the inference that we didn’t let folks know
about our books was pretty plain.
Records indicated that the correspondent
received The Kalends, and The Kalends had
rather conspicuously referred to A at least
3 times. Records also indicated that an-
nouncement of A had been sent to a list on
which the correspondent’s name appeared.
But that is far from the point. The point
is that 3 weeks prior to the writing of his
letter, the correspondent had purchased by
letter personally signed, 2 copies of A, and
a week after that had paid for the 2 copies by
personal check.
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
257
Lighthouse Observations
THE PATIENT WITH HEART DISEASE;
CONSIDERED AS A SURGICAL RISK
Physicians are often asked whether a particu-
lar person can safely undergo an operation, gen-
erally with reference to physical ability to with-
stand the shock of an anesthetic and the manipu-
lation of a major surgical procedure. Butler,
Feeney and Levine (Jour. A. M. A., 95; 85, July
12, 1930) have presented us with a review of the
case histories of 414 patients who were under ob-
servation at the Peter Bent Brigham Hospital, in
Boston, or were seen in private practice. None but
definite cases of organic heart disease were in-
cluded in the study; 120 cases of valvular heart
disease; 138 of so-called chronic myocarditis; 86
of permanent auricular fibrillation; 35 of angina
pectoris; 20 of coronary thrombosis; and a few
scattered cases of less common cardiac affections.
The analysis considers the type of operation per-
formed; character of heart lesion and age period of
the individuals in each of these groups; the rela-
tion of nephritis to the mortality recorded; and
the relation of blood pressure to the seriousness
of the varying conditions. The study is summar-
ized as follows:
(1) The 414 patients suffering from heart dis-
ease, who underwent 494 operations, were studied
in order to determine the risk of operation and the
role played by the heart in the outcome. Deaths
were divided into unexpected and inevitable.
There were 28 unexpected deaths; a mortality of
6.3%.
(2) Patients with valvular heart disease; 147
operations were performed on 120 patients; with
3 unexpected deaths — a mortality of 2.1%.
(3) Among 138 patients having chronic myocar-
ditis, there were 8 unexpected deaths in 167 opera-
tions— a mortality of 4.9%; these patients were
mostly older persons and tolerated operation well.
(4) There were 108 operations performed on 87
patients with auricular fibrillation, with 3 unex-
pected deaths — a mortality of 3%. Contrary to the
general opinion, the risk of operating on such pa-
tients is not great.
(5) There were 41 operations performed on 35
patients having angina pectoris, with 3 unexpected
deaths — a mortality of 7.7%. There seems to be a
slight risk of coronary thrombosis following in the
wake of surgical intervention upon patients with
angina pectoris.
(6) There were 20 operations performed on the
same number of patients with coronary throm-
bosis; 8 unexpected deaths — a mortality rate of
44.5%.
(7) Of patients with syphilitic aortitis, 11 were
submitted to 13 operations; with 1 unexpected
death.
(8) There were 6 patients with paroxysmal
tachycardia, 3 of whom had attacks during opera-
tion and 3 after operation ; all recovered.
(9) There were 50 operations performed on as
many patients with congestive heart failure; 7
unexpected deaths- — mortality rate 17.1%.
(10) There were 433 operations upon 359 pa-
tients having heart disease without nephritis; 20
unexpected deaths — a mortality of 4.9%. Among 61
operations performed on 55 patients having heart
disease with nephritis, there were recorded 8 un-
expected deaths — a mortality of 14.8%; which well
illustrates the increase in risk resulting from the
presence of nephritis.
(11) Survival of the patient with heart disease
is not the only consideration. Conditions for which
there are nonoperative palliative methods of treat-
ment should not be subjected to surgery when the
heart disease is so great that the ultimate life ex-
pectancy, at best, is short.
(12) In most types of heart disease, the surgical
risk is not appreciably greater than in the normal
person. In some where the risk would - be great,
it may be materially diminished by proper pre-
operative diagnosis and therapy.
VOCAL CORDS OF METAL
Metal vocal cords are restoring the power of
speech to persons who have become mute. An
artificial larynx which, when attached to the
throat, functions in all respects like that of na-
ture, is one of the latest products of scientific
research, according to a report issued by the En-
gineering Foundation.
The new artificial larynx, prepared by Dr. R.
R. Riesz of the Bell Telephone Laboratories, New
York, is a thin metal reed, clamped at one end
and free at the other, and can be attached to the
windpipe by a rubber tube and coupling pad.
When air is expelled from the lungs and direct-
ed through this larynx, it sets the metal reed to
vibrating, and the speaker, by the ordinary mo-
tions of tongue, lips, and throat muscles, trans-
forms the vibrations into speech.
So complete is the mechanism that by a simple
adjustment one can change the pitch of the vi-
brations, producing the tones of either a man or a
woman. The instrument is thus adapted to use by
both sexes. Dr. Riesz (Literary Digest, Nov. 22,
1930.) explains:
“Speech sounds in general may be divided into
2 groups. In the first group are placed all the
‘voiced’ sounds, in the production of which the
vocal cords play an important part. Vowels, semi-
vowels, diphthongs, transitionals, and voiced con-
sonants are members of this group. The second
group comprises the ‘unvoiced’ sounds, in the pro-
duction of which no sound is generated by the
vocal cords. The unvoiced sounds in general are
produced in the mouth. For the voiced sounds, the
source is the larynx; where there is a pair of
exceedingly adjustable lips — the vocal cords
which during ordinary breathing are drawn out
of the way, allowing air to pass freely to and
from the lungs. When a person desires to pro-
duce a sound, the vocal cords are drawn close to-
gether, leaving but a narrow slit between them.
As the lungs force a current of air through this
slit, the cords vibrate, changing the current of air
into a pulsating sound-wave which is modified by
the cavities of the throat, mouth, and nose, and
emerges as recognizable speech.
Instead of a pair of vocal cords, the vibrating
element in the artificial larynx is a thin metal reed,
clamped at one end and free at the other. One of
the metal tubes leading from the artificial larynx
is connected by means of a rubber tube and coup-
ling pad to the termination of the windpipe on the
front of the neck. The user blows air from his
lungs through the larynx, setting the metal reed in
vibration. This vibration generates a train of
sound-waves similar to that generated by the vocal
cords of a normal person.
The fundamental frequency of sound must be
about 125 vibrations per second for a man’s voice
and 250 vibrations per second for a woman’s voice.
258
JOURNAL OF THF. MEDICAL SOCIETY OF NEW JERSEY
March, 1931
An adjustment is provided for changing the pitch
of the larynx so that it can be used by either men
or women.
The sounds of the unvoiced group are produced
by blowing air through the larynx in such man-
ner that the metal reed is not thrown into vi-
bration.
A breathing hole in the side of the instrument
enables the user to inhale air into his lungs. This
hole he covers by pressure with his thumb when
he wishes to speak.
By practice, persons can become very proficient
at speaking with an artificial larynx, and so be re-
stored to the useful normal activities which at-
tend the power of speech.”
Current Events
THE PHYSICIANS’ ECONOMIC CONTRIBU-
TION TO THE COMMUNITY
(An abstract of the Presidential Address of Charles
Gordon Heyd, M.D., to the Medical Society
of the County of New York)
The Medical Society of the County of New York
is dedicated to the proposition that:
(1) The fundamental object of medical practice
is to provide and make available adequate, effec-
tive and efficient medical service at all times for
every member of the community, regardless of
race, color or creed.
(2) Medical service as provided today is in a
large measure effective and efficient although not
always adequate or available.
(3) The payment to physicians for medical ser-
vice is not a large item in the so-called cost of
medical care, as only about 50% of patients hos-
pitalized in general hospitals pay a doctor’s fee.
(4) There is no logical reason for believing that
the professional item for adequate and effective
medical service in the cost of medical care can be
materially lessened or reduced; on the contrary,
there are many reasons for believing that it will
be increased, as it must eventually have added
to it a charge for professional services.
(5) The doctor is a citizen and must discharge
all of his obligations of citizenship the same as
any other member of the community.
(6) The doctor is entitled to a monetary return
(or his labor that is fair and commensurate with
his service, training and experience; the fact that
the practice of medicine is a profession does not
mean that the doctor shall continue to work under
a system that is ethically wrong and economically
unsound; he must be paid for his services in order
to function as a useful and contributing member
of society.
These postulates present the background for my
remarks and serve as an introduction as to what
is the economic contribution of physicians to the
community.
It is claimed by competent statisticians that
physicians treat % of the population of the
United States free of charge. Since at all times
there are 2% of the population incapacitated and
about 4% physically impaired, it follows that from
375,000 to 500,000 persons are daily treated with-
out charge. If only $2 per person were charged
tor treatment, the sum total monetary equivalent
lor contributions annually made by physicians in
the form of free medical treatment would be $365,-
000,000. If all the medical and quasi-medical foun-
dations were consolidated into one organization
their entire contribution to society in dollars dur-
ing the last 20 years would not equal the annual
donation of the physicians of the country. The
medical profession may, therefore, justly claim
that under the present medicosocial system it
stands without a rival in the entire field of medi-
cal charity and health philanthropy.
In this connection it is interesting to note that
only 4,000,000 Americans submit any income tax
reports at all and, in 1927, 1,600,000 of these paid
no taxes because exemptions exceeded net income.
As returns are expected when income reaches
$2500 for a married person, or $1500 for a single
person, these figures throw a powerful search-
light upon the phenomenon of our ability to pay
for things. Assuming 27,000,000 heads of families,
less than 10% of them had income sufficient to
warrant the preparation of a tax return with the
expectation of making payment. It follows that
with only 43% of the community gainfully em-
ployed and 87% of the community receiving less
than $2000 a year, no matter how much the cost
of medical service can be reduced, it cannot be
reduced sufficiently low to allow this large group
of persons to pay for medical services out of in-
come.
One of the fundamental difficulties in consider-
ation of the high cost of illness is that the pub-
lic has not been educated to realize that a certain
sum of money must be expended to keep the
human machine in a state of efficiency.
There are approximately 450,000 persons passing
through the wards of the New York hospitals
in a year; practically 1,500,000 other citizens
avail themselves of the dispensaries. It is evident
that this entire group of people, nearly 2,000,000,
makes no provision for paying a physician or for
pei iodic visits to the doctor. A very important
aspect of the problem is that when sickness ap-
pears the cost and expenditure under the present
system of payment is an immediate one, forced
and made under stress. Out of every 100 who
borrow from small loan companies, an average
of 28 persons do so because of expenditures aris-
ing from illness or death. Interest rates on these
loans vary from 12 to 42% per annum, which ma-
terially increases the burden of the average wage
earner with a family.
There is hardly a member of the community who
is gainfully employed that would not be able to
handle a reasonable professional charge, in keep-
ing with his economic position, if the load or
charge were spread over a sufficient period of time.
It seems inevitable that we must come to some
scheme whereby the cost of professional attention,
oi even the hospital, might be spread over a
sufficient number of months to enable the patient
to liquidate his indebtedness and be a self-respect-
ing, responsible member of the community. It
is not for the best interests of society that such
a large body of the population should be remiss
in its rightful obligation and obtain medical
services free of charge. It is not good public
policy to disburse money given or donated, or ex-
tracted from the public by taxation, for such wide-
spread hospital and medical services.
It would be a splendid move in social medical ad-
justment (1) to curtain the unrestricted system of
gratuitous relief, by excluding those not entitled
to gratuitous medical advice; (2) to insist on pay-
ment of the medical staff, even those engaged in
out-patient work, and the payment of fees by
patients in the pay ward and in the consultation
departments of voluntary hospitals.
March. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
25&
If the doctor could be assured of, let us say, a
minimal revenue from all the patients that he
takes care of he could well afford to permit a re-
duction on some percentage of his work. But what
is attempted, if one may judge from recent news-
paper publications, is to oblige the doctor to con-
tinue his free medical service and at the same
time accept a reduction in his charges to the pa-
tients that he takes care of and who are occupy-
ing certain types of rooms which are essentially
private hospital accommodations.
It .would appear that the time is not far distant
when the County Medical Society must decide
whether as an organization it shall enter into what
may be termed the business of medicine. It is
apparent that with our nearly 4000 members
we have a sufficient clientele to seriously consider
the establishment of an insurance bureau, or even
an insurance company. It might also suggest
itself that there could be formed and managed
under the auspices of the County Medical Society
a credit and funding society, a collecting bureau,
and we might even go so far as to organize the
personnel for the management of clinics.
It might be considered the proper function of
the Bureau on Publicity of the Medical Society of
the County of New Y'ork to devise and draw up
a list of zones within the city so that persons in-
quiring for competent medical service could be
given a list of properly qualified physicians, mem-
bers of the County Medical Society residing or
practicing within the zone, and to make available
to the inquiring public the names of certified
specialists residing or practicing in certain desig-
nated zones.
PRESENT STATUS
STATE SOCIETA-RUTGERS’ POST-GRAD-
UATE COURSE
The committee is offering this year 6 distinct
courses from which the county societies may select
according to local choice. In each county local
committees are working with the State Society
Committee and representatives of Rutgers, en-
deavoring to meet the desires of each group and
to enlist as many students as possible. To us the
plans seem very attractive, and we hope our
readers will carefully inspect the following syn-
opses of lectures and list of exceptionally talented
teachers engaged, and then communicate with
their own county society committee about sub-
scribing.
Synopsis of Lectures on Cardiac, Vascular and
Renal Diseases
Lecture I. Diagnosis from the etiologic, anatomic
and physiologic viewpoints. Elementary electro-
cardiography. Discussions of cardiac arhythmias. — -
Dr. Arthur De Graff.
Lecture II. Rheumatic heart disease — Bacterial
endocarditis. — Dr. Irving Graef.
Lecture III. Thyroid heart disease — Essential
hypertension. — Dr. William Goldring.
Lecture IV. Syphilitic heart disease — Degenera-
tive (arteriosclerotic) type of heart disease. — Dr.
De La Chapelle.
Lecture V. Heart failure. Types; Clinical Pic-
tures; Course; Treatment. — Dr. John C. Wyckoff.
Lecture VI. Classification of Bright’s disease — -
Urine Sediment count — Kidney in pregnancy
(Eclampsia.) — Dr. William Goldring.
Lecture VII. Function of normal kidney — Renal
insufficiency — Uremia; Kidney function tests. —
Dr. Norman Jolliffe.
Lecture VIII. Prognosis; clinical course; treat-
ment of hypertension and various types' of
Bright’s disease. Treatment of uremia. — Dr. Will-
iam Goldring.
Outline of Newer Therapy Course
/
Lecture I. Introductory Lecture: (a) Pharma-
cology of drugs; (b) scientific methods of study of
therapeutic agents; (c) principles of dosage; (d)
the place of mixtures in modern drug therapy; (e)
rational versus empiric drug therapy; (f) the
proprietary drug problem; (g) the Council on
Pharmacy and Chemistry; (h) “Useful Drugs”
and “New and Nonofficial Remedies”.
Lecture II. Diuretics; (a) Newer conceptions of
the diuretic action; (b) organic mercurials —
novasurol and salyrgan; (c) urea; (d) acid-form-
ing diuretics — ammonium chloride; (e) theocin.
Lecture III. Circulatory Drugs: (a) Purines —
coronary vasodilators; (b) camphor and its deriva-
tions— cardiazol; (c) barium chloride; (d) quinidin;
(e) drugs for the reduction of blood pressure — •
sodium sulphecyanate, cucurbocitrin, bismuth sub-
carbonate.
Lecture IV. Digitalis.
Lecture V. Digitalis, continued.
Lecture VI. Hypnotics — analgesics — anesthetics:
(a) The barbituric acid group; (b) fixed anesthe-
tics; (c) mixed analgesics in labor.
Lecture VII. Recent studies in the treatment of
anemia: (a) Liver extract; (b) stomach extract;
(c) copper.
Lecture VIII. Hormones and glandular products:
(a) Pituitary; (b) insulin; (c) miscellaneous.
Outline of Obstetrics Course
Lecture I. Antenatal care: General care; im-
portance of cardiovascular -renal systems; pelvi-
metry; types of pelvic deformity; border-line con-
tractures; forming an estimate of labor.
Lecture II. Abortion; miscarriage; placenta pre-
via; abrupto placentae; other sources of ante-
partum and intrapartum hemorrhage.
Lecture III. Obstetric forceps: Indications;
contraindications; varieties and special indications
for each; manikin demonstration and practice.
Lecture IV. Version; breech extraction; mani-
kin demonstration and practice.
Lecture V. Management of third stage; manage-
ment of puerperium; complications of pregnancy;
of the puerperium ; labor anesthesia.
Lecture VI. Puerperal sepsis.
Lecture VII. Toxemias of pregnancy.
Lecture VIII. Postpartum gynecology of obstet-
rics: Postpartum follow-up; epdocervicitis; cer-
vical erosions; uterine displacements; prophylactic
and nonoperative treatment.
Outline of Pediatrics Course
Lecture I. Feeding problems in infancy. A sim-
ple practical method, with illustrative cases. — Dr.
Charles Hendee Smith or Dr. Gaylord W. Graves.
Lecture II. Periodic health examinations and
preventive pediatrics. Methods, records and in-
structions to parents. Defects foupd. Cases dem-
onstrated.— Dr. Gaylord W. Graves or Dr. Jose-
phine H. Kenyon.
Lecture III. Malnutrition in childhood: Among
school and pre-school children. Diagnosis and
treatment. Clinical demonstrations. Lantern. — Dr.
Hugh Chaplin or Dr. Edward S. Rimer.
Lecture IV. Tuberculosis in Childhood. Acute
(in infancy) and “infectious” (latent) in older
children. Lantern cases. — Dr. Charles Hendee
Smith or Dr. Edith M. Lincoln.
Lecture V. Heart disease in childhood and oral
260
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
infections. Prevalence, importance, diagnosis, treat-
ment, clinical cases. — Dr. Lucy Porter Sutton or
Dr. Alfred Langmann.
Lecture VI. Differential diagnosis of pulmonary
diseases. Pneumonias* empyema, abscess, bron-
chiectasis, nilus nodes. With cases. — Dr. Howard
H. Mason or Dr. Charles Hendee Smith.
Lecture VII. Endocrine disorders and develop-
mental defects. Goiter, cretinism, dyspituitarism,
thymus, mongolism, dwarfs, mental defects. — Dr.
Herbert B. Wilcox or Dr. John B. Caffey.
Lecture VIII. Subject and lecturer to be chosen.
Four electives of which one may be chosen: (a)
Acute disease in childhood; (b) laboratory aids to
diagnosis: (c) acute infectious diseases; (d) sensi-
tization in childhood.
Outline of Course in Gynecology
Lecture I. Etiologic significance of prominent
gynecologic symptoms. Disorders of development
and function; malformations, amenorrhea, dys-
menorrhea, intermenstrual pain. Methods of exam-
ination.
Lecture II. Infections of female pelvic organs;
(a) Septic genital infections (non-specific); (b)
septic urinary infections; (c) specific infections.
Lecture III. Diseases of vulva and urethra. Dis-
eases of vagina.
Lecture IV. Diseases of uterus: Endometritis;
lacerations and displacements.
Lecture V. Diseases of uterus continued; tumors.
Lecture VI. Diseases of fallopian tubes: Inflam-
SCHEDULE OF CLASSES
AS ARRANGED TO DATE— FEBRUARY 20
First Lecture Time of Meeting
Course
Given at
Starts
Meeting Place'
Day
Hour
Drug Therapy
Atlantic City
April 1
Atlantic City Hospital
Wed.
8:30
p. m.
Drug Therapy
Trenton
April 2
Mercer Hospital
Thurs.
8:00
p. m.
Gynecology
Trenton
April 7
St. Francis Hospital
Tues.
4:00
p. m.
Pediatrics
Trenton
April 3
Mercer Hospital
Fri.
8:00
p. m.
Pediatrics
Newark
Mar. 20
Presbyterian Hospital
Fri.
8:45
p. m.
Cardiac
Newark
Mar. 18
Academy of Medicine
Wed.
8:45
p. m.
Gastro-enterology
Newark
Mar. 20
Academy of Medicine
Fri.
8:45
p. m.
Combination course:
4 lectures on Gastro-
enterology
4 lectures on cardiac
diseases
Camden
April 1
Camden Dispensary
Wed.
4:00
p. m.
Combination course :
4 lectures on obstet-
rics
4 lectures on gyne-
cology
Bridgeton
April 2
Bridgeton Hospital
Thurs.
4:00
p. m.
Gastro-enterology
Somerville
Mar. 16
Somerset Hospital
Mon.
8:30
p. m.
♦Gynecology — Combina-
tion course
Newton
Mar. 26
Thurs.
8:30
p. m.
General course
Mt. Holly
Mt. Holly Hospital
New Brunswick
Combination course
4 lectures on gyne-
cology
4 lectures on obstet-
rics
Hackensack
May 1
Hackensack Hospital
Fri.
3:30
p. m.
Combination course
Gastro-enterology —
4 medical and 4 sur-
gical
Paterson
April 3
Health Center
Fri.
8:30
p. m.
Obstetrics
Jersey City
April 6
Jersey City Medical
Center
Mon.
4:00
p. m.
Gastro-enterology
Jersey City
April 4
Jersey City Medical
Center
Sat.
4:00
p. m.
Pediatrics
Elizabeth
Mar. 18
Elks Club
Wed.
8:30
p. m.
Gastro-enterology
Elizabeth
Mar. 19
Elks Club
Thurs.
8:30
p. m.
REMARKS :
♦There will be a combination course in Newton. Three of the lectures will be on gynecology.
The local committee has not decided definitely the subject for the other lectures.
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
261
mation, ectopic pregnancy, tumors. Diseases of
the ovaries; inflammation and tumors.
Lecture VII. Office gynecology.
Lecture VIII. Indications for surgical treatment;
after treatment of gynecologic operations.
Outline of Gastro-Enterology Course
Under the direction of Mills Sturtevant, M.D.,
Clinical Professor of Medicine, New York Univer-
sity.
Lecture I. Gastro-intestinal symptoms as an ap-
proach to diagnosis. Gastric neuroses. Gastric
functional diseases. Gastroptosis. Gastric symp-
toms in diseases of other organs.— Dr. Mills Stur-
tevant.
Lecture II. Gall-bladder disease. Liver function
tests and their value to the general practitioner. —
Dr. Norman Jolliffe.
Lecture III. Diseases of the esophagus. — Dr.
Robert P. Wallace.
Lecture IV. Peptic ulcer: Etiology — pathology
— symptomatology — types — diagnosis — roentgen-
ology.— Dr. Louis L. Shapiro.
Lecture V. Peptic ulcer; medical treatment. —
Dr. Mills Sturtevant.
Lecture VI. Peptic ulcer; surgical treatment in-
cluding perforation and the relation of ulcer to
carcinoma.- — Dr. Arthur Wright.
Lecture VII. Tumors of the stomach and intes-
tines: Diagnosis; pathology; and treatment. — Dr.
Irving Graef.
Lecture VIII. Diarrhea; constipation; colitis;
diagnosis of rectal disease. — Dr. M. P. Cowett.
Faculty
The lecturers have not been selected for all cen-
ters but we can now name some prominent doctors
from New York and Philadelphia who will give
lectures. In Jersey City, they are using a com-
bination of local men with New York personnel.
The following doctors have already accepted invi-
tations to lecture:
Mills Sturtevant, New York
Norman Jolliffe, New York
Robert P. Wallace, New York
Louis L. Shapiro, New York
George Stewart, New York
Irving Graef, New York
M. P. Cowett, New York
Wm. Goldring, New York
De La Chapelle, New York
John C. Wyckoff, New York
Arthur Wright, New York
Arthur DeGraff ,New York
Hai’ry Gold, New York
Cary Eggleston, New York
Alfred C. Beck, Brooklyn
W. E. Caldwell, New York
John Osborn Polak, Brooklyn
John C. Gittings, Philadelphia
W. Wayne Babcock, Philadelphia
Charles H. Smith, New York
Gaylord W. Graves, New York
Josephine H. Kenyon, New York
Hugh Chaplin, New York
Edward S. Rimer, New York
Edith M. Lincoln, New York
Lucy Porter Sutton, New York
Alfred Langmann, New York
Howard H. Mason, New York
Herbert B. Wilcox, New York
John B. Caffey, New York
FIFTH COUNCILLOR DISTRICT MEETING
We are informed that an interesting program
is in process of development for a joint meeting of
all the county medical societies of this district —
embracing Atlantic, Cape May, Cumberland, Glou-
cester and Salem Counties, to be held in Atlantic
City on Friday, April 10.
An afternoon session will be devoted to discus-
sion of economic problems introduced by distin-
guished members of the profession invited because
of their knowledge of such matters, and that ses-
sion will be followed by a dinner at the Hotel Chal-
fonte.
An evening session will then convene at the At-
lantic City Hospital where an address upon some
scientific subject, by Dr. Joseph C. Doane, of Phila-
dephia, will be associated with clinical demonstra-
tions by members of the hospital staff.
It is expected that this district meeting will be
well attended. It should be, with such an attrac-
tive program.
Public Relations
DISCLOSURE OF DISEASES UNDER
PROHIBITION ACT ABOLISHED
(Editorial Jour. A. M. A., Feb. 7, 1931.)
Physicians who prescribe liquor need not state
on the stubs of their prescriptions the ailments for
which it is prescribed. The item on the stubs of
outstanding prescription blanks calling for this
information may be ignored. When new prescrip-
tion blanks are printed, the item calling for such
information will be omitted. The Wickersham
Commission, in its report released January 20,
recommended that physicians prescribing under
the National Prohibition Act be no longer required
to state on blanks going into the public files the
ailments for which prescriptions are given. Two
days, later, the Commissioner of Industrial Alcohol
issued a circular letter instructing all supervisors
of permits under the act that , ailments need no
longer be stated on the stubs of prescriptions and
directed them to advise the physicians in their
several districts to that effect-. Physicians are still
required, by the National Prohibition Act itself,
to keep in their offices book records of prescrip-
tions for liquor, including records of the ailments
for which it is prescribed, subject to inspection by
prohibition officers.
WARNING TO PHYSICIANS
(Editorial New England Jour. Med., Dec. 25, 1930.)
Most of the physicians of the state, registered
under the Harrison Narcotic Law, have no doubt
by this time received their warning notice rela-
tive to re-registration and payment of special tax
on or before July 1 of each year.
We trust that all have given due consideration
to the second paragraph and have correctly in-
terpreted its significance. “Section 9 of the Har-
rison Narcotic Law provides that anyone who vio-
lates or fails to comply until any of the above re-
quirements shall, on conviction, be fined not more
than $2000 or be imprisoned not more than 5
years, or both, in the discretion of the court.”
The medical profession, it will be seen, under a
law of the land of the free and the home of the
brave, constitutes a privileged class. It is privi-
262
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
leged to prescribe narcotics on the payment of a
special tax which allows it to assume the privilege
of bearing the financial burden of narcotic con-
trol; its members are given the privilege of
languishing in jail, fortunately for a period of not
more than 5 years, if by a simple error of omis-
sion they should fail to fulfill an imposed obliga-
tion on a certain date.
Perhaps the court, in its infinite mercy, might
not impose the extreme penalty; perhaps incon-
venience, indignity and humiliation might be the
only penalty involved in a given instance; never-
theless the specific penalty is provided by law and
to no one is it guaranteed that he will not suffer
it if he innocently fails to fulfill the requirements.
Here, if ever there was one, is a wrong which
needs to be righted. Here is an instance of legis-
lation gone awry. A learned profession, a pro-
fession which ministers to the needs of others, a
profession which has little interest in or aptitude
for practical politics must suffer from discrimina-
tory legislation of the less intelligent sort. How
long must this continue?
THE NEW ENGLAND MEDICAL CENTER
The New England Medical Journal of February
5, 1931, contains a report of the proceedings at-
tendant upon laying the corner-stone of the first
of the buildings for this new project. In the same
Journal is a letter from Dr. Otis, for many years
an eminent teacher and practitioner of medicine
in Boston, upon the passing of the country doc-
tor and the development of medical centers. These
literary contributions bear so directly upon the
question we discussed in our issue of last Novem-
ber— when we suggested utilization of centrally
placed county hospitals, under control of the
county medical society, as medical centers — that
we take pleasure in presenting abstracts of each
for your consideration.
“The honor of laying the corner-stone was given
to Dr. Merritt H. Eddy, of Middlebury, Vermont,
the oldest family doctor in New England. Dr. Eddy
came to Boston on his ninety-eighth birthday to
take part in these exercises. He is a graduate of
the University of- Vermont College of Medicine
(class of 1865) and for 65 years has been practicing
his profession. As it is the purpose of the New
England Medical Center to assist in the training
of general practitioners for New England, it was
eminently fitting that the laying of the corner-
stone be done by the oldest living physician in
the New England States.
After the laying of the corner-stone Dir. Rotch
introduced Dr. Alfred Worcester, Professor of Hy-
giene at Harvard College, who delivered a short
address :
'We old-fashioned country doctors are delighted
with the building of this Health Center. For we
believe that in it not only will there be larger
provision for the sick but also far better facilities
for training young doctors to be general prac-
titioners.
Medical science can be learned from lectures
and books and in the laboratories. But the art of
medical practice, like every other art, can be learn-
ed only by imitation, that is, only by apprentice-
ship under masters of the art. The Boston Dis-
pensary has always afforded such opportunities to
medical students. Indeed in its earliest years, be-
fore there were any hospitals in this part of the
country, this was the only place where group
teaching of medical students was possible. Nearly
a half century ago I myself learned more here
than in any other clinic.
We old general practitioners have for many
years been fearing that in the marvelous advance
of medical science the art of practice is being lost.
But this need not happen. Specialists we must have
for no one can now, as formerly, be equally pro-
ficient in all branches of medical practice. And
although in some of the specialties master of the
art of practice is not so indispensable as it is to
the general practitioner, yet in every one of the
specialties medical students can be taught and
ought to be taught how to treat the patient him-
self while learning how to treat his disease.
However great the need may be for specialists
the greater need just now is for general practition-
ers, who. answering every call by either night or
day, will do all they possibly can for the relief
of the sick and suffering. Such doctors must know
at least enough of the specialties to summon the
aid of specialists when such service is needed. They
must also know enough for emergency service
when there is no time to lose, and when so far
away as to make the summons of a specialist prac-
tically impossible. For, as ought to be more gen-
erally known, in many emergencies the patient
has better chances from early, even if somewhat
crude, service than later he would have from the
service of the most expert.
In this new Health Center, as we confidently
believe, it will be possible to give future medical
students just the kind of training needed for gen-
eral practice.’’
The following message is from the letter of Ed-
ward O. Otis, M.D., Emeritus Professor Tufts Col-
lege Medical School:
“In a recent memorial to a very worthy coun-
try doctor in Vermont occurs this significant state-
ment: ‘There is no question that “the country doc-
tor” is passing.’ If this, as it appears to be, is
the case, is there not good reason why this should
not happen in the general advance and progress
of medical science? I believe that something bet-
ter is to take the place of the old-time family
practitioner, but I do not believe that it will be
accomifiished by trying to replace what we have
known as the ‘country doctor’. After a student of
medicine has spent 7 to 8 years in preparing him-
self for practice, at a large expense of time and
money, he will rarely be willing to take up an or-
dinary country practice and establish his home in
a small community. Furthermore, having been
trained at a first-class medical school, he has
learned the necessity of near-by facilities of a
well-equipped hospital. He knows that he can-
not in many cases make an accurate diagnosis
without the aid of laboratory and x-ray facilities,
and therefore, besides the other reasons, he is un-
willing to go into the country where these facili-
ties are not readily available. In my service as
teacher at the Tufts College Medical School for
the last 25 years, I have met many of my old
pupils in different parts of the country, but I
have found few who have settled as country doc-
tors. Therefore, in the march of time and progress,
it will not avail much to look ‘mournfully upon the
past’ of the country doctor, but to see how his
place can be better filled through better knowl-
edge of medical science and treatment. Many sug-
gestions have been offered; the first requisite is
to supply everyone, rich and poor alike, with mod-
ern medical service. This, it seems to me, might
be done through smaller medical centers through-
out New England, at which centers there should
be a well-equipped hospital with a lying-in depart-
ment and with a high-grade personnel. Such a
center could easily, it seems to me, serve an area
within a radius of 10 or 15 miles through the pres-
ent system of good roads, the automobile and tele-
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
263
phone. Doubtless other plans of affording ade-
quate medical service to everyone can be sug-
gested— but one thing seems evident to the observ-
ant modern physician, and that is that the country
doctor as he existed previously is fast passing and
times and conditions have changed. It is well
that it is so — although we take off our hats to
him as he passes with bowed shoulders but head
erect.”
ANNOUNCEMENT OF THE FIRST AWARD
UNDER THE THOMAS W. SALMON
MEMORIAL
Dr. Adolf Meyer, Professor of Psychiatry, Johns
Hopkins LTniversity-, has been chosen to receive
the first award under the recently established
Thomas W. Salmon Memorial. Announcement to
this effect was made Saturday, January 10, at a
meeting held at the New York Academy of Medi-
cine at which an endowment fund of $100,000
contributed by friends and associates of the late
Dr. Salmon was officially presented to the Academy
and active work under the Memorial was begun.
The award was made by a committee appointed
by the Academy to survey the field and select
the outstanding contributor to scientific advance
in mental medicine, and Dr. Meyer was selected in
recognition of his distinguished services to psychi-
atry and mental hygiene over a period of years.
The award carries with it an honorarium of $2500
and the recipient will give The Thomas W. Sal-
mon Lectures during 1931. The dates of the lec-
tures and the places at which they are to be de-
livered will be announced later.
Dr. Meyer is an outstanding man among the
psychiatrists of the world and has been for many
years a leader in the development of his specialty.
A teacher from his earliest days in the United
States, his influence on psychiatry expressed
through his pupils is well known abroad. Conserva-
tive and sound, but with broad vision, and at all
times in contact with his anatomic, neurologic,
physiologic and psychobiologic laboratories, he
has given a powerful stimulus to the building up
of a dynamic and progressive conception of psychi-
atry.
Not generally known is the fact that Dr. Meyer
is the man who suggested and first used the term
“mental hygiene” and gave the mental hygiene
movement its name. By that very naming of this
great movement, with which he has been identified
from the very beginning, he gave it the initial im-
petus and forward-looking, comprehensive pro-
gram. He was one of the original organizers of the
National Committee for Mental Hygiene, the
agency largely responsible for development of the
mental hygiene movement in this country and the
world over.
School Health Department
SPECIAL MEETING OF SCHOOL PHYSICIANS
Allen G. Ireland, M.D.,
Director of Physical and Health Education, State
Department of Public Instruction, Trenton, N. J.
The meeting of school physicians inaugurated
last June at the Annual Convention of the State
Medical Society will be repeated this year. The day
is Wednesday, June 3, in the afternoon. The place
is the Berkeley-Carteret Hotel, Asbury Park. Watch
this column for further announcements.
American Association of School Physicians
This infant society, now about 3 years old, is
enjoying phenomenal growth. This month it cele-
brates the appearance of “The School Physician’s
Bulletin”, a neat appearing, promising journal
which, hereafter, -will be published monthly.
The secretary of the Association is Dr. William
A. Howe, of the State Department of Education,
Albany, New York.
A New Jersey physician, Dr. Brinkerhoff, chief
of the medical inspection department of Jersey
City schools, is one of the vice-presidents.
Notes of Interest
Unique Recording and Filing System. The indi-
vidual examination record cards of the pupils are
filed by classrooms. The guide card has the grade,
the teacher’s name, and the summary of the physi-
cal defects of the class. Thus, at a glance, one can
tell the needs of the group. As a defect is cor-
rected, the child’s name is crossed off in red ink.
The nurse who devised this system reports it as
more satisfactory than the method of having de-
fects reported on separate forms. Each time she
consults this new file, the existing needs are re-
peatedly brought to mind.
Weight and Height. The American Child Health
Association announces abandonment of its height-
weight charts. This is the outcome of an exten-
sive research throughout the country with school
children. The report is contained in a booklet en-
titled “Present Practices in the Light of Research”.
The address of the Association is 370 Seventh
Avenue, New York City.
Crippled Children. “The Crippled Child” is the
name of a monthly journal published by “The In-
ternational Society for Crippled Children, Inc.”,
located at Elyria, Ohio. It is said to be the only
magazine published in English on the problems
of the crippled child.
Mental Hygiene. Dr. Uel W. Larkin, President
of the National Education Association, said at its
last convention: “Never before has there been
so much general interest in safeguarding the men-
tal health of school children. It is significant that
approximately 20 courses have been introduced into
our colleges and universities to train visiting
teachers, workers who are equipped with an under-
standing of psychology, mental hygiene and social
adjustment. The visiting teacher will in time re-
place the attendance officer. Instead of maintain-
ing a police force to keep children in school, we
shall draw them there by the intelligent and
friendly guidance of teachers who understand the
problems of childhood.”
Joint Committee. The Joint Committee on
Health Problems of the American Medical Associa-
tion and the National Education Association an-
nounces the revised edition of its famous report
“Health Education”. It is certainly worth having,
even better than the 1924 edition which sold to
the extent of 75,000 copies. Address the National
Education Association at 1201 Sixteenth Street,
Washington, D. C.
Reports from the Field. This office is receiving
glowing accounts of your field secretary’s (Mrs.
264
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
Taneyhill) success in putting over her new talk
on mental hygiene. More requests for her ser-
vices are coming in than we can meet. It is one
more indication of the great interest in mental
hygiene.
In Lighter Vein
Hand Him a Fan
Sam, who had just fulfilled a lifetime ambition
and bought a fur coat, went strutting down the
street. He met a poor friend, shivering with cold,
who said :
“Say, Sam, it’s pretty cold today, ain’t it?”
“Is it?” said Sam, peering out from the depths
of his fur collar. “Now, you know, I really haven’t
looked at the paper today.”— Wall Street Journal.
No Sale
Sporting goods salesman (who has talked golf
for an hour) : By the way, I don’t know if you
are interested in golf. I hope I haven’t been
boring you.
Girl customer: Not in the least — but tell me,
what is golf? — Gocd Hardware.
The Planet’s Complaint
“What’s wrong with the world, anyway?” asked
the first pessimist.
“Too much rope is being used for making cigars
and not enough to hang gangsters,” growled the
other one. — Cincinnati Inquirer.
On a Strafing Cruise
Mother — “Why ever are you sitting there when
you ought to be in bed?”
Peter — “There’s a mosquito in my room.”
Mother — “It hasn't bitten you, has it, darling?’’
Peter — “No, but it came close enough for me
to hear its propeller.” — Humorist (London).
Speaking of teamwork we’ve noticed that it’s
usually the case when a family is fighting to keep
the wolf from the door that the stork takes the
opportunity to slip down the chimney. — Ohio State
Journal.
One doesn’t hear anything about the dangers of
kissing any more, so we suppose the educational
campaign must have broken up that deadly habit.
— Ohio State Journal.
“My advice to those who want to live to a good
old age,” says a doctor, “is — walk slowly.” Those
who follow this advice should take the precaution
of keeping to the sidewalk.— The Humorist.
Master-Mind
The bridegroom was in a poetic frenzy as he
strolled along the seashore. “Roll on, thou deep and
dark blue ocean, roll”, he recited to his bride.
“Oh, Gerald”, she exclaimed, “how wonderful you
are. It’s doing it.” — Exchange.
Funny Finny Stuff
Did you ever stop to think that a fish may go
home and lie about the size of the bait he hooked?
— Judge.
May I Cut In?
Friend: Isn’t your youngest son a surgeon?
Actor (proudly): Yes; he opens in Bellevue Hos-
pital tonight!
Woman’s Auxiliary
WOMAN’S PART IN MEDICAL HISTORY
Some months ago we read, in the New England
Medical Journal probably, a suggestion that in
paying tribute to those physicians who pioneered
in the use of chloroform and ether as anesthetics
it might not be amiss to consider the heroism of
the first patients who submitted to such anesthesia.
Now there comes to our attention the report of a
ceremonial in Kentucky, where, at the unveiling
of a statute to Dr. Ephraim McDowell, an ap-
propriate tribute was paid to his patient on the
historic occasion when he performed the first
ovariotomy.
The Woman’s Auxiliary to the Kentucky Medi-
cal Association played an important role on that
occasion, and it occurs to us that many similar
events might be arranged in our several states
by the local auxiliaries — events that would serve
at least as acknowledgement of debts long unpaid
to men and women patients who served humanity
quite as effectively as and perhaps more heroically
than the surgeons who devised and performed new
operations.
We reproduce from the Kentucky Medical
Journal of January 1931 an account of the incident
to which we have referred.
Jane Todd Crawford — The Model Patient*
By Mrs. P. E. Blackerby, Past-President
Woman’s Auxiliary to the Kentucky State Medi-
cal Association, Louisville, Ky.
It is peculiarly gratifying to the Woman's Aux-
iliaries to the Kentucky State and the Southern
Medical Associations that we should have been
invited to be represented on this historic occasion
when the medical profession is paying its tribute
to the memory of Ephraim McDowell, of whom
Dr. David W. Yandell, when contrasting the
fame of the statesmen, the orators and the military
men of Kentucky with that of McDowell, said:
“Chief among all of these is he who bears the
mark of our guild, Ephraim McDowell ; for the
labors of the statesmen will give way to the
pitiless logic of events, the voice of the orator
grows fainter in the coming ages, and the deeds of
the soldier eventually find place only in the library
of the students of military campaigns, while the
achievements of the village surgeon, like the
widening waves of the inviolate sea, shall reach the
uttermost shores of time hailed by all civilization
as having lessened the suffering and lengthened
the span of human life.”
In the history of no other state or nation has
its medical profession contributed more glorious
pages as the record of its service to humanity
than have the physicians of Kentucky. Towering
among these stands this pioneer surgeon, whose
lineaments stand revealed before us by the art of
the sculptor, to live forever as a memorial to one of
the greatest servants of mankind. It is fitting
that this monument should be presented to the
Commonwealth so glorified by its organized medi-
cal profession. It is fitting that it should proudly
stand in the Rotunda of our beautiful Capitol, that
all who behold it in these Halls of State may be
stimulated by his illustrious example. Physicians,
yes, statesmen and citizens, too, may better serve
their kind by familiarizing themselves with the
"(Delivered at the Unveiling of the Niehaus Statue of Mc-
Dowell in the Capitol, Frankfort, Ky., November 15, 1930.)
.larch, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
265
itory of this man and by dwelling upon the ma-
ured product of his labor, as the great orator of
his occasion has so well done.
It is fitting, too, that a woman should have been
;elected to pay the tribute of womankind to the
nan whose courage and scientific study opened
v-hat seems to us as the magic doors which restore
lealth and peace and comfort and usefulness. TV e
ire appalled as wTe contemplate the untold suffer -
ngs of our sex through the ages before McDowell
naugurated the era of modern surgery. One shud-
lers as one thinks of the hopeless horror of the
niserable sufferer condemned helplessly to her
leathbed.
Picture for yourself the scene on those winter
lays of 1809, when Jane Todd Crawford lay suffer-
ng in her farm home, in Green County. Already
he mother of 5 children she had experienced the
xtremity of pain and the happiest reward within
he hope of her sex — motherhood. Now, however,
tretched upon her bed of pain, the kindly minis-
rations of her family -were only able to make her
?onscious of their love and sympathy. She was
fiessed, as all are blessed who have that happy ex-
perience, with the service of her family physi-
cian. Women know best what this means. Too
’requently they, themselves, are the sufferers from
illness. When they are not, the strain upon them
is the greater, for the child they have borne or
the husband and helpmate is in danger. Then,
oesides her faith in the Great Physician, her
human helper is her family physician. It is he
who alleviates the pain, assuages the fever, exor-
cises the infection, inculcates confidence, restores
hope. Mrs. Crawford was fortunate in having
such intimate guidance, and yet there arrived the
time when the family physician became hopeless,
too. And, as family physicians, realizing their
responsibility for a human life, have always done,
and will always do, her family physician sought
the aid of the foremost specialist of his time, the
first surgeon of the scattered community that had
so recently been transformed from an Tndian hunt-
ing ground to a proud, though still feeble, Com-
monwealth.
Responding to this urgent call Dr. McDowell
rode over the but recently marked trail through
the woods from Danville to her home. He found
her trouble really to be an ovarian tumor, imme-
diately threatening a fatal end.
To quote the graphic description of Dr. Samuel
Gross:
“After a most thorough and critical examination,
Dr. McDowell informed his patient, a woman of
unusual courage and strength of mind, that the
only chance for relief was excision of the diseased
mass (an ovarian tumor). He explained to her,
with great clearness and fidelity, the nature and
hazard of the operation, he told her that he had
never performed it, but that he was ready if she
were willing, to undertake it, and risk his repu-
tation upon the issue; adding that it was an ex-
periment, but an experiment well worthy of trial.
Mrs. Crawford listened to the surgeon with great
patience and coolness, and at the close of the in-
terview, promptly assured him that she was not
only willing but ready to submit to his decision;
asserting that any mode of death, suicide excepted,
was preferable to the ceaseless agony which she
was enduring, and that she would hazard any-
thing that held out even the most remote pros-
pect of relief. The result has been long before the
profession. Mrs. Crawford submitted to the op-
eration, and thus became the first subject of
ovariotomy.”
This courageous woman was 47 at the time of
the operation, and, as a result of it her life was
extended 31 more years and she died in 1841 at
the age of 78.
In his description of the operation, Dr. Mc-
Dowell stated that Mrs. Crawford had been affect-
ed with continuous pains for which she could find
no relief. After having determined that it was a
tumor of the ovary, he states: ‘‘Having never seen
so large a substance extracted, nor heard of any
attempt or success attending any operation such
as this required, I gave to the unhappy woman in-
formation of her dangerous situation. She appear-
ed willing to undergo an experiment, which I
promised to perform if she would come to Dan-
ville, the town where I live, a distance of 60 miles
from her place of residence. This appeared almost
impracticable though she performed the journey
in a few days on horseback.”
Mrs. A. T. McCormack has graphically drawn a
picture of the scene:
“For a moment, let us go back to that primitive
operating room improvised in the home of Dr.
McDowell, in Danville, which is still standing, and
visualize the scene.
The room is rather bare and quite cold, too, for
it is a wintry day, this December 13, 1809. In the
center of the room, near the window, is a long
wooden table covered with a folded blanket. On
this lies a woman patient — not in surgical gown
and stockings, but apparently, fully dressed, her
head resting on a pillow covered with a white slip.
Her abdomen, deformed by the massive growth,
forms a veritable hill under the light blanket that
covers her.
She is a courageous woman, a quiet, practical
woman, unafraid of plunging into the unknown, a
pioneer all her life, used to the hardships and the
hazards of the frontier, yet a woman of fine feel-
ing and tender sensibilities. But, here she is
pioneering in a new field. Pioneering for you and
for me even though she did not realize it.
Actually, she is about to submit to an experi-
ment on her own body, one that had never bef oi e
been accomplished. Her abdomen is to be de-
liberately cut open with a knife by this equally
brave and equally heroic man, several years
younger than herself, all for the purpose of de-
termining whether or not he can relieve her
agony by removing this painful growth from her
interior. It is a new experiment, and, although the
outcome is questionable, she is determined to carry
through her share in it.
But — how does this woman feel under these cir-
cumstances? What does she say and do during
that 25 minutes’ ordeal?
From her grandson, James Crawford Brown, it
was learned that during the operation she occu-
pied herself repeating the Psalms. The strength,
the beauty, the sustaining power of the Psalms to
a brave woman, who was also an idealist, could
scarcely be better demonstrated, for Jane Craw-
ford had no other comfort, not even a relative
standing near, no anesthetic whatsoever, either
local or general, not even a hypodermic of mor-
phin, for neither anesthetics nor morphia had been
discovered. She had only a supreme faith in her
Heavenly Father, a hopeful dependence in her
surgeon and the indomitable courage of a wonder
woman to carry her through this crucial ordeal
that has blazed the trail of abdominal surgery,
266
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
bringing its inestimable relief to countless thou-
sands of women since. And — let us remember
that although today the blessed relief of anes-
thesia brings total oblivion for the patient, Jane
Crawford went through the experiment perfectly
conscious of every movement, every word and
every glance of the surgeon and his assistants. To
restrain her involuntary muscles, men held down
her arms and legs with force in order to permit
the surgeon to work.”
Dr. McDowell concluded his description of the
operation and its results as follows: “In 5 days I
visited her, and, much to my astonishment, found
her engaged in making her bed. I gave her par-
ticular caution for the future and she returned
home, as she came, in good health, which she con-
tinues to enjoy.”
Upon the occasion of the dedication of the monu-
ment to McDowell at Danville in 1879, Dr. Lewis
Sayre, of New York, then President of the Ameri-
can Medical Association, said:
“Another fact strikes me very forcibly, Mr.
President, and that is the heroic character of the
woman who permitted this experimental opera-
tion to be performed upon her. The women of
Kentucky in that period of her early history were
heroic and courageous, accustomed to brave the
dangers of the tomahawk and scalping knife, and
had more self-reliance and true heroism than is
generally found in the more refined society of city
life; and hence the courage of Mrs. Crawford, who,
conscious that death was inevitable from the dis-
ease with which she suffered, so soon as the village
doctor explained to her his plan of affording her
relief, and convinced her judgment that it was
feasible, immediately replied, ‘Doctor, I am ready
for the operation; please proceed at once and per-
form it.’ All honor to Mrs. Crawford! Let her
name and that of Ephraim McDowell pass down
in history together as the founders of ovariotomy.”
Dr. Samuel D. Gross, one of the famous sur-
geons of the world, said:
“All honor to the man who had the courage and
skill to do that which no man had ever dared to do
before! All honor, too, to the heroic woman who,
with death literally staring her in the face, was
the first to submit calmly and resignedly to what
certainly was at the time a surgical experiment.
To her, too, let a monument be erected, not by
the Kentucky State Medical Society nor by the
citizens of Kentucky, but by suffering women,
who, with her example before them, have been the
recipients of the inestimable boon of ovariotomy,
with a new lease on their lives and with immunity
from subsequent discomfort and distress. I know
of no greater example in all history of heroism
than that displayed by this noble woman in sub-
mitting to an untried operation.”
To these tributes from these great authorities
I am honored today to add my humbler note, my
meed of praise to this heroic, pioneer woman and
to urge those who contemplate this noble monu-
ment to consider, along with the fame of the sur-
geon, the essential part played by this model pa-
tient.
It is in the program of the Woman's Auxiliary
to the Kentucky State Medical Association to some
day fittingly honor the memory of Jane Crawford
with a service similiar to this which brings us here
today. Thoughtful physicians and grateful woman-
hood will encourage our efforts in this direction.
Atlantic County
Reported by Mrs. W. Blair Stewart
Friday, February 13, was not in any way a hoo-
doo day, for the Atlantic County Medical Auxiliary
gave a very successful and delightful musical-tea
in the Solarium on the twentieth floor of Hotel
Claridge, a skyscraper for the seashore! This was
given to honor the President of the Woman’s Aux-
iliary to the Medical Society of New Jersey, Mrs.
John Nevin, of Jersey City. Mrs. James Hunter,
Jr., of Westville, Gloucester County, a Past-Presi-
dent, was also a guest.
At 1.30 p. m. the regular business of the aux-
iliary was transacted, after which the hotel or-
chestra gave a choice program of music with Mr.
William Stoking as leader. An hour’s program
of vocal and instrumental numbers was given by
Atlantic City talent.
Addresses were given by both the State Aux-
iliary President and by the Past-President, upon
the work of the auxiliaries, the fine work accom-
plished, and what may be accomplished.
The Claridge Hotel should be called the house
of hospitality, for the management did everything
possible to make our musical-tea a success.
Essex County
Reported by Mrs. F. J. McCauley
The regular meeting of the Essex County Aux-
iliary was held on January 26 at the Nurses’ Home
of the Newark City Hospital. Mrs. John Nevin,
our State President, addressed the meeting with
her usual good cheer and a message advising us
to read the Journal.
Following this, Dr. Henry Barkhorn, of Newark,
President of the Essex County Medical Society,
gave us a very enlightening talk on medical wel-
fare work and current medical legislative meas-
ures.
Later, we had a well attended tea.
The report of our Scholarship Fund Chairman,
that we had swelled our treasury fund by the last
card party to the extent of $150, was very reas-
suring. Plans have been completed for a theater
benefit performance to be given on Monday and
Tuesday, March 9 and 10, at the Lyceum Theater
in East Orange. The play is the popular comedy
“Pigs”.
The parent teaching classes held monthly at the
Y. W. C. A. are well patronized; the average at-
tendance is about 125.
Twenty thousand pamphlets explaining the ma-
ternity work being carried on through the Y. W.
C. A. have been sent to the physicians in Essex
County Society for distribution among their pa-
tients.
Copies of Dr. E. .T. Ill's speech at the convention
in Atlantic City last June, on the Widows and
Orphans Society, are being sent to every member
in the State Society and all the men who are not
members will be asked to join.
Gloucester County
Reported by Mrs. Henry B. Diverty
A meeting of the above auxiliary was held at
the home of Mrs. Elwood I. Downs, January 28,
at 8 p. m. All of the officers and many members
were present.
The business meeting was unusually interesting-
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
267
is not only our county business was discussed but
)Ur part in the coming American Medical Associa-
ion Convention to be held in Philadelphia, June
5-12, 1931.
A social hour followed.
February Meeting
The Woman’s Auxiliary of the Gloucester County
Medical Society held a meeting at the same time
md place as the physicians, 9 p. m., Hotel Pitman,
Pitman, N. J. All officers and a goodly number of
?ther members present. All committees reported
progress. Ways and Means were discussed and ar-
rangements made for Gloucester Auxiliary s part
n the A. M. A. convention to be held in Philadel-
jhia, June 8 to 12. After adjournment we joined
the physicians in the dining room where a fine
rollation was served, adding much to the social
lour.
Hudson County
Reported by Miss Anne Hetherington
The regular meeting of the Woman’s Auxiliary
to the Hudson County Medical- Society was omitted
in January in order that the members might de-
vote themselves solely to the mid-winter card
party held on February 4, in the Jersey City
y. W. C. A. A steadily increasing interest in this
annual event was shown by a larger attendance
than ever; the spacious auditorium being filled
with players and their friends who came in later
for tea. Mrs. George Culver was chairman of the
day.
The President, Mrs. John Nevin, had as her
guests Mrs. H. Roy Van Ness, of Newark, Presi-
dent-Elect of the State Medical Society Auxiliary;
Mrs. Theodore Teimer, of Newark; Mrs. Joseph
Morrow, of Ridgewood; and Mrs. Winfield Kilts, of
Teaneck, President of the Bergen County Auxil-
iary.
Mrs. Nevin made a strong plea for a large atten-
dance at the State Medical Society Convention to
be held in June at Asbury Park, outlining the fine
program planned for entertainment of the Woman’s
Auxiliaries.
Mercer County
Reported by Mrs. George N. J. Sommer
While the county medical society members at-
tended the meeting at the Carteret Club in Tren-
ton, their wives were left at “Fannie Gerson’s
Shop”, West State Street, for the auxiliary meet-
ing, after which bridge and a buffet supper were
enjoyed.
Mrs. George N. J. Sommer, as Director, and Mrs.
D. Leo Haggerty, President of the Branch, were
in charge of arrangements.
Reports were given by the chairmen of speak-
ers’ bureau; of the hospitality committee; of the
membership committee, and by the Treasurer.
“Medical Legislation” was the topic of the ad-
dress given by Dr. D. Leo Haggerty, member of
the Welfare Committee of the State Medical So-
ciety.
Ocean County
Reported by Mrs. E. G. Herbener
A meeting of the Woman’s Auxiliary to the
Ocean County Medical Society was held at the
residence of Mrs. Frank Denniston, 420 River Ave-
nue, Point Pleasant, Friday, February 6, at 3
p. m., with the following members present:
Madames V. M. Disbrow, Frank Denniston, F. N.
Bunnell, F. N. Bunnell, Jr., Alfred Woodhouse, B.
Sawyer, H. B. Disbrow and E. G. Herbener.
Mrs. Nevin, President of the State Society Aux-
iliary, was also present and gave a very interest-
ing talk about visits to the different county meet-
ings and how they were conducted; and she also
made several valuable suggestions on how to in-
crease our membership.
It was agreed that a card party be given, at the
American Legion Home at Toms River, April 3,
at 2 p. m. At the same time a business meeting
of the members can be arranged for.
A vote of thanks was given to Mrs. Denniston for
the delightful afternoon and the nice refreshments
served.
Union County
Reported by Mrs. H. V. Hubbard
The first of a series of afternoon meetings was
held by the Woman’s Auxiliary to the Union
County Medical Society in the Winfield-Scott
Hotel, Elizabeth, and 40 guests and members sat
down to the luncheon; physicians’ wives from all
over the county were present and Plainfield had a
very large representation.
The President and President-Elect of the Auxil-
iary to the New Jersey State Medical Society, Mrs.
John Nevin, of Jersey City, and Mrs. H. Roy Van
Ness, of Newark, were the guest speakers. Mrs.
Nevin brought a very encouraging report of her
visits to other county auxiliaries and told of their
activities and work accomplished, as well as of
their difficulties. Mrs. Van Ness gave an inspiring
talk on the 2 projects the Essex County Auxiliary
has started. The first is a series of lectures on
prenatal care and parenthood for women who
are neither very rich or poor and who lack the
opportunity to get such authentic information;
the other is a scholarship fund for worthy sons
or daughters of physicians.
Mrs. F. A. Kinch, of Westfield, a Past-President
from Union County, outlined the spring program
for the Auxiliary. Mrs. George L. Orton, another
Past-President, reported plans for the entertain-
ment of Auxiliary members at the meetings of the
New Jersey State Medical Society, in Asbury Park,
June 3-4-5, and those of the American Medical
Association, in Philadelphia, June 8 to 12.
Mr. Charles Audsley, of Rahway, accompanied
by Mrs. Orton, rendered 2 groups of songs during
the afternoon.
Mrs. Taney hill, Field Secretary of the New
Jersey State Medical Society, conducting its pro-
gram of- health talks and preventive medicine, re-
ported some of the benefits derived from atten-
dance at the national meetings in Detroit last year
and briefly outlined her work this year on Mental
Hygiene, which she will present in every county
in the state during the year.
Mrs. H. V. Hubbard, of Plainfield, President of
Union County Auxiliary, presided. At the close
of the meeting the following officers were pre-
sented to those present: President-Elect, Mrs. Har-
old Corbusier, of Plainfield; Vice-Presidents, Mrs.
Norman Currie, of Plainfield, and Mrs. George L.
Orton, of Rahway; Secretary, Mrs. Charles Hoff-
man, of Plainfield; and the Treasurer, Mrs. Den-
nis McElhinney, of Elizabeth.
The next meeting of the Union County Auxiliary
will be a luncheon-bridge held at Plainfield, in
March.
26S
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
County Society Reports
ATLANTIC COUNTY
John S. Irvin, M.D., Reporter
The regular monthly meeting of the Atlantic
County Medical Society was held at the Chalfonte
Hotel, February 13, at 8:30 p. m. The meeting
was called to order by the President, Dr. Norman
J. Quinn. The minutes of the previous meeting
were read by Dr. Joseph H. Marcus, secretary,
and approved as read. There were 43 members
present.
A communication was received from the Glou-
cester County Medical Society inviting the local
society to attend a meeting to be held February
19 at the Hotel Pitman, Gloucester.
There were 2 applications for membership, one
from Dr. Herman Kline, graduate of the Hahne-
mann Hospital of Philadelphia, and one from
Dr. Jesse D. Rork, graduate of Jefferson, June,
1924.
Dr. Joseph Poland asked whether a veterinar-
ian could be admitted to the society as an asso-
ciate member, and was informed that there was
nothing in the by-laws contrary to this.
The Treasurer’s report of January, 1931,
showed a balance of $665.71. A committee of 2,
consisting of Drs. Silvers and Carrington, was ap-
pointed to audit the account.
Report of Committees: Dr. W. Blair Stewart
spoke about a meeting of the Atlantic City Res-
taurant Association, in which the matter of the
“fly-by-night” eating houses who operate here in
the summer was discussed. In many cases these
restaurants and cafes are unsanitary. Ordinance
No. 44 governs restaurants and their sanitary ar-
rangements. The Restaurant Association is de-
sirous of having the Medical Society impress the
Mayor and the Bureau of Health that this Ordin-
ance is to be enforced. This ordinance says that
anyone with a communicable disease is barred
from working in restaurants and hotels; but it
does not go any further into the question of the
health of the employees. The question of having
employees examined physically before being al-
lowed to work was discussed.
It would be an easy matter to pick out major
difficulties, such as advanced cases of tuberculosis
and venereal diseases. The society should be will-
ing to cooperate with the restaurants and hotels
to check up on the health of employees and to
give them at least a reasonable bill of health,
and they should be willing to pay the doctors a
reasonable amount for the examinations. The
following motion was adopted: “The County So-
ciety endorses Ordinance No. 44 and requests that
the authorities make every effort to enforce it
during the coming year/’
Concerning the Daley Collection Agency, Dr.
Scanlan reported that Mr. M. R. Daley proposed
the establishment of a collection agency within
the society with himself as business manager,
but as this proposition was no different from any
other, collection agency, it is recommended -that
the matter be dropped. A motion to this effect
was passed.
Committee on Post-Graduate Study: Lectures
will be given by Rutgers University if there are
twenty members interested, and the cost for the
course will be $30.00. The lectures are to last
an hour and a half, as last year the 2-hour lec-
ture was considered too long. There will be one
man in charge, and the topic will be “Newer Drug
Therapy”. Literature in these courses will be
sent to the members shortly.
Dr. W. B. Stewart congratulated the members
upon having so well attended the Philadelphia
County Medical Society to hear the talk on the
heart; 18 members of the local society were in
attendance.
It was moved and seconded and unanimously
voted that Dr. Henry O. Reik should be made
an honorary member of the society in recogni-
tion of his excellent work.
The President introduced the speaker of the
evening, Dr. Clay Ray Murray, Associate Pro-
fessor of Surgery at the College of Physicians and
Surgeons, Columbia University, who spoke on the
“Treatment of Fractures.” (Paper to be pub-
lished later.)
Following his paper he showed a moving pic-
ture of himself treating a Pott’s fracture; a
talking moving picture, but unfortunately the
talking unit could not be used as it was for alter-
nating current while the current available was
direct. Dr. Murray covered this defect by talk-
' ing during the showing of the film.
Atlantic City Hospital Staff
Joseph H. Marcus, M.D., Secretary
The stated monthly meeting of the General
Staff, Atlantic City Hospital, was held in the
auditorium on the evening of January 23, under
President David B. Allman.
Dr. Allman: The report of a Surgical Service 6
months after its beginning might blur some of
the details of each individual case but the per-
spective of ideas and ideals of the service cer-
tainly has not been impaired. For the purpose
of record, a brief summary of the statistics is
necessary: Admissions on our service were 397;
of which 354 recovered, 25 signed releases and
18 died. There was a total of 147 free operations;
the largest number of cases ever treated in this
hospital on one service. Naturally, the period of
August, September, and October always has the
largest service because of the increased popula-
tion of this city during that time.
The service that I have just finished as chief
was my tenth, and I can well remember my first.
There was formerly ample work for one man,
who could very nicely use an assistant and, of
course, an intern, but with such help there was
no great stress or strain. Today things have
changed. Even with 1 competent assistant, 2
residents who devote their time solely to the ser-
vice, and the help of a capable Chief Resident,
the work has increased so in volume that it often
occupies more of one’s time than it is convenient
to give. This is in some measure due to the fact
that we have more patients, but more largely to
the fact that each patient receives more treat-
ment because there are more things to do and
newer methods — and in the traumatic cases be-
cause of the multiplicity of injuries. I can vis-
ualize the time, not far distant, when the Surgical
Service will be relieved of its fracture work and
still have ample to do. As a matter of fact, we
have already been relieved of most of the rectal
work and practically all our genito-urinary work
— and I, for one, can truthfully say “good rid-
dance”. And, although we surgeons will proba-
bly fight tooth and nail against loss of our frac-
ture cases, I do not doubt that 10 years hence
some Surgical Chief will report how “rushed to-
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
.269
death” he was in spite of the fact that he treated
no fractures.
While on the subject of fractures, I wish to
emphasize what has been said by several others,
and what I stated in my last annual report — they
are constantly becoming more complicated, more
unusual and more trying and difficult to treat.
Fractures of the skull are not operated upon now
with nearly the frequency of 10 years ago.
The Orr method has been a boon in the treat-
ment of osteomyelitis. It is the only condition in
which our work has been lessened rather than
increased — and where the number of hospital
days has been markedly diminished. It is radi-
cally different from our old method of daily re-
dressings. The operation consists, briefly, of a
gentle cleansing of the wound through a large
incision; removal of loose sequestra; painting the
interior with iodin and alcohol; packing the
wound with vaselin gauze; and applying a cast
which is not to be removed for 4 to 6 weeks in
most cases. Just how it performs its seeming
miracles is not quite clear, whether the meddle-
some interference of former days delayed heal-
ing of those caess, or whether action of the bac-
teriophage now hastens healing, but from a fairly
large experience I am fully prepared to say that
they do heal much quicker, with infinitely less
attention, and when the wound is finally healed
the patient is strong and robust and not a pale
nervous wreck.
Spinal anesthesia was used on my past service
in certain selected cases, much to my gratifica-
tion. It is not an a'nesthetic of ch.oice for routine
use, but it certainly has a definite field, and when
properly used at the right time is a most valuable
adjunct.
To handle as many thousands of cases as I have
seen in the wards without a case of tetanus, and
then to have 2 develop in rapid succession during
this service, makes one pause and consider. Both
patients were brought to our Dispensary imme-
diately following their accidents; both received
1500 units of antitoxin; both were promptly ad-
mitted to the ward; both developed tetanus; both
were actively treated; and both died. They were
not in the same accident — and one was only
slightly injured and was discharged as recovered
the day following his accident. The lesson to be
gathered from these 2 cases is, as reported at
our last clinic night, that in every suspected case
the prophylactic dose of antitoxin should be 3000
units, and 1500 units should be given every fifth
day thereafter until all danger has passed.
I have figured out that each ward patient ad-
mitted to this house receives the attention of
25-30 different highly trained individuals, all
acting as cogs in the wheels which bring about
his recovery — and the fact that these wheels run
so smoothly and so efficiently speaks well for the
organization of the hospital; and I take this op-
portunity to thank all who so kindly helped dur-
ing August, September and October, and whose
cooperation is essential for the continuance of the
excellent work that has been done and that we
are continuing to do.
A review of the 18 deaths which occurred on
our service follows: Of fractured skull cases, 4
were in a total of 14 hours; all of these patients
were severely shocked, all had complicating frac-
tures in other parts of the body, and none reacted
even to the slightest degree. There were 2 cases
of fractured pelvis and each died within 3 hr.
after admission. One of these patients had a
fracture of both arms and both legs, in addition,
and the other was the ‘‘parachute jumper” from
the Steel Pier — our first case after taking over
the service — who had a complete tear through
the perineum and through the abdominal wall
with evulsion of his intestines, rupture of the
bladder and other complicating internal injuries.
One case of ruptured lung died 6 hours after
admission.
Pour patients died of ruptured gangrenous ap-
pendicitis, all from toxemia — 3 were rather elderly
people and 1 a child 3 yr. old; 3 of the 4 cases
were sent in by local physicians not members of
our Staff, and the fourth was a woman, 6 0 yr.
old, sent in by a Staff member 3 days after he
had made the diagnosis and 3 days after he had
insisted upon operation.
One death was due to gunshot wounds of the
head and neck; a colored adult who had an alter-
cation with her sweetheart. The bullet wounds
in her skull were numerous and at no time was
the condition such as to warrant operation.
A patient with very severe, compound, badly
comminuted fracture of the femur died 3 days
after admission, never having reacted from shock.
Another with multiple compound fractures of the
left tibia and fibula, with severing of all muscles
and tendons, and profuse hemorrhage, died 2 hr.
after admisssion.
One man, aged 68 died of toxemia from a viru-
lent spreading cellulitis of the thigh.
A gall-bladder case terminated 1 day after op-
eration for reasons which we were not able to
ascertain, as an autopsy was not obtainable. The
woman was in good general physical condition
prior to operation; temperature 100°, pulse 96,
and respirations 22; mild nephritis; leukocyte
count of 21,500, of which 90% were polymorpho-
nuclears. Immediately following operation, her
temperature jumped to 104° and pulse to 110;
pulse later reached 120, where it remained until
death, and temperature varied between 102° and
104° axillary.
A death from nephritis occurred, in a young
man, 21 yr. of age, 1 month after admission be-
cause of an automobile accident in which he re-
ceived a very bad compound, comminuted frac-
ture of the right humerus with extensive lacera-
tions of the skin and muscles. In spite of blood
transfusion , and all other recognized forms of
treatment, this boy gradually became more toxic
and finally died. While he was moribund it was
ascertained that he had been refused life insur-
ance 3 yr. prior to this accident because of a
nephritis, and that explained the fact that his
nephritis, which we assumed to be toxic in origin
and due to the accident, did not respond to treat-
ment.
The eighteenth death was a case of suicide in a
colored woman 6 0 yr. old, which occurred in our
ward. She was admitted with a huge, strangu-
lated hernia and intestinal obstruction. An opera-
tion „was advised and refused and the patient
died 48 hr. after admission from toxemia.
As we look back upon the large number, of
cases — 39 7 — which we handled on our service,
and when we deduct from the total number of
deaths the 8 patients who died within 24 hr. after
admission and 1 patient who refused to take our
advice, we do not feel that 9 deaths on an active
traumatic service is more than should reasonably
be expected.
Dr. Walter B. Stewart. Report of Pediatric Ser-
vice: In a review of the second and fourth quar-
ters of the pediatric service of 19 30 it is gratify-
270
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931 j
ing to observe a rapid increase in the number of
admissions to the ward. The majority were of
great diagnostic interest. Nutritional and res-
piratory cases occurred, as usual, in about equal
number. More cases of lobar pneumonia than of
any other one condition occurred, 12 out of 96,
or 4 times as many as of bronchopneumonia.
However, contrary to the usual supposition, the
mortality from lobar pneumonia in children is
low, only 1 death among these 12 cases; but 2
deaths of the 3 cases of bronchopneumonia. Death
occurred in 16 of the 9 6 cases summarized. In
6 of the 16, necropsy was done; an average of
38%, a figure considerably below that of the pre-
ceding year. Tuberculosis took the greatest toll;
5 of the 16. Acute gastro-enteritis and pneumonia
took 3 each; congenital defects took 2 (1 an in-
fected myelocele, and 1 cardiac anomaly); star-
vation, acute encephalitis, and streptococcus men-
ingitis each took 1. It is worth noting that no
case of meningococcus meningitis was admitted
during this period. There was 1 case of typhoid
fever.
Many of these cases have shown such interest-
ing features that the histories should not be filed
without recording a few points. Since the chief
complaint in 3 of them was almost identical —
painful, swollen, immobile legs — let us consider
the differential diagnosis. All 3 developed symp-
toms during' their first year. Each was brought
to the hospital because of pain on passive motion
of the lower extremities, which were swollen, par-
tially flexed, and apparently paralyzed, because
of the absence of active motion. The painful
joints of rheumatic fever can be eliminated at
once because of the age. Poliomyelitis can be ex-
cluded because of the acute tenderness present.
None of them was rachitic; enabling us to rule
out the multiple fractures of rickets. In the first
child, aged 3 mo., the cause was congenital syphi-
lis, and the symptoms appeared at 2 mo. There
was no active motion in either the upper or the
lower extremities, except the fingers. Passive mo-
tion was very painful. The underlying lesion is
an epiphysitis. Restoration of function was rapid
and complete within 3 days of the onset of treat-
ment with mercurial inunctions. This syndrome
develops typically from syphilis during the first
few months of life.
Symptoms in the second case, a child of 12 mo.,
were caused by an acute osteomyelitis. The swell-
ing and immobility were unilateral, involving the
right lower extremity. The swelling was greatest
just below the knee. There was very little super-
ficial redness. However, the high fever and the
prostration indicated a deep-seated, acute infec-
tion. The osteomyelitis involved the shaft of the
right tibia, which was curetted by Dr. Allman,
packed with vaselin gauze, and put into a plaster
cast. A rapid and beautiful recovery resulted.
Scurvy was the diagnosis in the third case, a
child aged 9 mo. This is the first condition to
suspect in an infant during his second 6 months
of life whose mother gives the following story:
“The baby has been increasingly fretful and irri-
table, particularly when I go to change his dia-
pers, or move his legs. He won’t kick any more,
but just lies there with his legs partially flexed,
and yells when I touch him. I've fed him on
condensed milk and have given no orange juice.”
This story makes the diagnosis. The gums around
the upper incisors may or may not be red and
swollen. The pain in these cases is caused by
subperiosteal hemorrhages. Orange juice cured
within 2 days. Suspect an error in diagnosis if
such a case, the child being under 12 mo. of age,
has been called rheumatism.
It is not always easy to be sure of the presence
of a non-opaque foreign body in the bronchus of
a child. This boy, aged 14 mo., was admitted
with signs typical of a foreign body in the left
main bronchus; almost complete suppression of
breath sounds front and back on the left side,
and marked emphysema on the left side. How-
ever, no foreign body was rendered visible by
x-rays. The onset had been sudden, 6 days be-
fore, when the child had a severe coughing spell
while playing on the floor. He had coughed fre-
quently and paroxysmally since that time. Res-
pirations were normal, except that at times in-
spiration grew labored and at times there was an
audible wheeze, with typically asthmatic rales.
No cyanosis or chest retraction. Temperature not
above 100°. At times the breath sounds were nor-
mal posteriorly but were always suppressed an-
teriorly. He appeared to be getting better rather
than worse. This variability in signs seemed to
indicate that the position of the foreign body in
the bronchus shifted from time to time. Bron-
choscopic examination revealed a small piece of
tinfoil in the left main bronchus, which was re-
moved successfully.
The next case is one of generalized enlarge-
ment of the lymph-nodes presenting unusual fea-
tures. The diagnosis lies between tuberculosis
and Hodgkin’s disease, the weight of evidence
favoring the former. The patient was a 6 yr.
old colored girl who during the preceding 2 yr.
had a firm, easily visible enlargement of the left
inguinal gland- and of the cervical lymph-nodes;
the former was the size of an English walnut,
while other nodes were palpable but small. There
had been no recent increase in size, and none had
softened or broken down during this period of 2
years. Radiograph showed the mediastinal nodes
as large masses on both sides, extending well out
into the parenchyma of the lung. General nutri-
tion good. At no time during 5 weeks of obser-
vation did the temperature go above 100°. Intra-
dermal tuberculin was negative to 0.1 mgm, but
positive to 1 mgm. Two blood Wassermanns
were negative. Erythrocytes and hemoglobin were
almost normal. Leukocytes numbered 9 000 to
12,000; polys 70%; lymphos. 28%; eosins 2%.
The histologic picture of a lymph-node obtained
at biopsy was inconclusive, showing only inflam-
matory reaction. In favor of tuberculosis were
the greater frequency of occurrence, especially in
a colored child, typical appearance of the medias-
tinal nodes, and positive tuberculin. Against
tuberculosis were involvement of the inguinal
nodes, good nutritional condition, failure to soften
or break down, and normal temperature.
Two cases of acute encephalitis occurred, 1
with recovery, 1 with death. Tuberculosis men-
ingitis had been the first diagnosis in both. The
first, a colored boy of 20 mo., had been ill for
2 weeks with restlessness, irritability, piercing
cries, occasional vomiting, loss of weight, and at-
tacks of muscular twitchings. Low grade fever,
not over 101°. Marked malnutrition with begin-
ning dehydration. Marked rigidity of neck and
body. Extreme irritability. Spinal fluid under
high pressure, with increase of globulin and pel-
licle formation, but a cell count of only 4. Dur-
ing a month in the ward the symptoms subsided,
and the weight increased from 15% to 19 lb.
Tuberculin tests and Wassermann reactions were
negative. It will be interesting to follow this
child for the possible development of postence-
phalitic syndrones.
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
271
The other instance of acute encephalitis, in a
colored boy of 6 yr., had a duration of 5 days
from the onset with severe pains in the head up
to the death in coma. Fever of 102° to 107° and
numerous convulsions followed. Pupils small and
fixed. No rigidity. Spinal fluid under moderate
pressure, with increase of globulin and formation
of pellicle, and cell count of 2 6, all small lympho-
cytes. Necropsy revealed no evidence of tuber-
culosis, but only focal congestion in the brain.
Two cases of dysentery caused by the dysentery
bacillus (Hiss-Russell) will be mentioned because
of the late development of the condition, the
onset of the one on Oct. 7 and of the other on
Oct. 10. Dysentery is usually met here in August
or early September, rarely as late as October.
Eoth were severe and typical cases, with blood-
streaked watery stools containing mucus and pus.
They were handled successfully by an initial star-
vation period with intraperitoneal injections of
normal salt solution, followed by increasing
amounts of reinforced protein milk with dextri-
maltose, i. e. skimmed buttermilk with junket
curd.
The last case is one of lung abscess in a girl
of 8 years. Five days after removal of her ton-
sils and adenoids severe pain developed in the
lower left chest. Several days later 11 oz. bloody
serous fluid were aspirated from this side. She
was admitted 3 weeks after the operation because
of recurrence of pain in the chest and a persis-
tently elevated temperature of 101° to 104°. In
spite of all the physical and roentgenographic
signs of fluid in the left side, 3 attempts to ob-
tain fluid failed to yield a drop. Evidently the
main lesion was one of unresolved pneumonia.
Three weeks after admission temperature was
still 101° to 103°, but the signs indicated resolu-
tion of the general process. However, radio-
graph showed a localized area of thickening and
of retracted pleura, suggesting an abscess. Dr.
Johnson inserted a needle in the mid-axillary re-
gion and obtained a small amount of thick green-
ish pus from a small cavity which could not have
held over 60 c.c. Convalescence has been rapid
since drainage of the abscess.
BERGEN COUNTY
Charles Littwin, M.D., Reporter
The regular meeting of the Bergen County
Medical Society was held at Holy Name Hospital,
Tuesday evening, February 10.
The minutes of the Annual Meeting and also of
the Executive Committee were read and ap-
proved.
Approval of the appointments to the Executive
Commitee was voted.
The recommedation of the committee, that
delinquents be notified by registered mail that
unless their dues be paid in full by the March
meeting they would be suspended, was moved
and passed.
Applications for membership of Drs. J. Willis
Demarest, Franz Kastler, and Trevalyn W.
Omstead were read.
Drs. King and Hallett brought up the subject
of “courtesy to the physician in court”. Both
have recently waited all morning without pur-
pose. It was regularly moved and passed that
the Executive Committee take up this subject
with the Bar Association.
The program for the evening was presented
by Dr. Louis Rene Kaufman, M.D., F. A. C. S.,
Professor Urology and Head of Urologic Section
Flower Plospital; his subject being “Recent Ad-
vances in Diagnosis and Treatment of Urologic
Lesions; Uroselectan; Prostatectomy”. The talk
was illustrated by original motion picture film.
BURLINGTON COUNTY
Roscius I. Downs, M.D., Reporter
A regular meeting of the Burlington County
Medical Society was held Wednesday afternoon,
January 14, in the Burlington County Plospital, at
Mount Holly, under the President, Dr. Joseph M.
Ruder, with 14 members present.
Because the State Medical Society decided to
continue the Post-Graduate course of instruction,
Dr. Kuder had appointed the following com-
mittee: Drs. Richard D. Anderson, Chairman;
Howard C. Curtiss and Marcus W. Newcomb, to
determine upon the course desired, time and
place of meeting, and to give assistance in organ-
izing our membership into groups subscribing to
these courses. Dr. Anderson’s report stated:
that questionnaires were sent to 49 doctors, that
13 replies were received and 7 would take the
course, but it is necessary to have an enrollment
of 20 to have the course given at Mt. Holly.
There were 3 applicants elected to membership:
Drs. P. H. Corpening, of Marlton; Eugene A.
Meyer, of Moorestown; Francis H. Borzell, of
Philadelphia.
Dr. Richard Anderson was elected Historian of
the Society, as Dr. Joseph Stokes felt that he
had not the time necessary for the work.
A letter of resignation from Dr. I. W. IPollings-
head was read, and received with regret.
Dr. Harry L. Rogers, Chairman of the Section
on Practice of Medicine, took charge of the meet-
ing and announced the following program:
“Agranulocytosis”, by David S. Farley, M.D., of
Philadelphia.
“Consideration of the Causes of Diarrhea”, by
E. W. Rodman, M.D., of Beverlyj N. J.
Dr. Farley commenced by saying that the term
agranulocytosis means an increase of granular
cells, while the disease really shows a decrease
of the granular cells, therefore, agranulocytopenia
is a better term. In 1922, agranulocytic angina,
a rare and fatal condition, was described. The
causes of this disease are divided into 3 groups:
first is from chemicals, mainly following the use
of arsphehamin; the second,' is from radiation,
as following the use of radium and x-rays; the
third is from unknown causes and is by far the
largest group.
The characteristics are leukopenia with pro-
nounced reduction of polymorphonuclear neu-
trophiles, decrease of blood-platelets, alteration
in bone marrow. There is no change in the
erythrocytes or hemoglobin; no purpura or bleed-
ing.
Three cases were described. The first followed
administration of neo-arsphenamin. A man, 3 3
yr. of age, complained of soreness of the mouth
and eruption of the skin. He had been given 5
doses of neo-arsphenamin at weekly intervals.
After the fifth dose he had sore throat and con-
junctivitis. He was given the sixth dose and de-
veloped sore throat, jaundice, a toxic condition,
enlarged spleen, a typhoid type of fever and died
in 11 days. Another case was of a child 3 yr. of
age, following an influenzal attack, Marked pallor.
272
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
yellow skin, marked anemia, enlarged liver and
spleen developed.
The treatment is symptomatic. Use sodium
theosulphate in arsenic cases as soon as possible.
Use many blood transfusions, radiation of the
long bones, ultraviolet light, liver extract. Shock
treatment consists of intravenous injection of
typhoid vaccine, and also the use of fixation ab-
scess by injection of turpentine. This last is quite
painful. The abscess must be opened.
Dr. Rodman’s paper was so definite and com-
plete that the society requested its publication in
full in the Journal.
C AM DUX COUNTY
R. S. Gamon., M.D., Reporter
The monthly meeting of the Camden County
Medical Society was held Tuesday, February 3,
at 9 p. m. Dr. E. G. Hummell, Vice-President,
presided in the absence of Dr. W. J. Barrett,
President, who is on vacation in Florida.
This meeting was the annual Case Report Night
and the program consisted of the following:
(1) “Loss of Sugar Tolerance in a Diabetic’’, by
Dr. A. J. Casselman.
(2) “Two Cases of Stone in the Urethra’'', (with
lantern slides), by Dr. D. F. Bentley, Jr.
(3) “Epidemic Cerebral Spinal Meningitis with
Recovery and Secondary Total Nerve Deafness”,
by Dr. Jos. E. Lovett.
(4) “Streptococcus Faucitis with Erythema No-
dosum and Erythema Multiforme Exudativum”,
by Dr. Hyman I. Goldstein.
(5) “Sub-total Gastrectomy for Carcinoma of
the Pylorus” (with lantern slides), by Dr. P. M.
Mecray.
(6) “A Case of Appendicitis with an Unusual
Complication”, by Dr. E. Shull.
(7) “Bilateral Congenital Dislocation of Hips”
(with lantern slides), by Dr. O. Carlander.
The Committee on Rutgers Post-Graduate Ex-
tension Work reported that applications will be
in the hands of members in the near future.
Drs. E. A. Y. Schellenger, 414 Cooper st., Cam-
den, and Max Ruttenberg, 210 State st., Camden,
were elected to membership.
Appropriate action was taken upon the death
of Dr. E. E. DeGrofft, Woodstown, who passed
away January 6, 1931.
The meeting was well attended.
ESSEX COUNTY
E. LeRoy Wood, M.D., Reporter
The Essex County Medical Society was host to
the Medical Societies of Union, Morris and War-
ren Counties which together constitute the First
Judicial Council District of the State Medical So-
ciety, Thursday evening, February 12, 1931.
The Essex County Medical Society elected 9
new members: William M. Brams, George M.
Cohn, Geza M. Frank, Harry Klein, Sol Parent,
Christopher J. Reilly, Henry M. Woolman, and
A. Russell Sherman, all of Newark; C. Franklin
Turner, Montclair.
Dr. Henry C. Barkhorn, President of Essex
County Medical Society, called attention to a
series of meetings being held each Wednesday
evening at 8.15 at the Academy of Medicine in
Newark to consider the subject of “Industrial
Poisonings”. The meetings have been organized
by the Safety Council and endorsed by the Medi-
cal Society. There will be 4 meetings, February
18, February 25, March 4, and March 11, ad-
dressed by prominent members of the profession,
authorities on their subjects.
Dr. E. G. Wherry, Chairman of the Medical
Milk Commission, offered a resolution, which was
passed by the society, supporting the use of
clean raw milk in certain cases in preference to
pasteurized milk. The resolution backed the
stand taken recently by Dr. J. G. Lipman, Di-
rector of the State Agricultural Experiment Sta-
tion at New Brunswick, in opposing “an organized
effort by milk dealers to eliminate raw milk as
a market commodity even though such raw milk
may be entirely safe to use and of greater food
value than pasteurized milk”.
The medical milk commission called attention
to the fact that certified milk, produced and dis-
tributed raw under medical supervision, “affords
utmost security in this most important article of
human food”. Dr. Lipman’s opinion was ex-
pressed in a letter to the International Associa-
tion of Milk Dealers which had asked his opinion
on the advantages of pasteurized milk. He re-
ferred to pasteurization as “the lesser of 2
evils” and declared health officers are “right in
insisting on pasteurization of all but the finest
grades of raw milk”.
The medical society resolution read: “The
question of the place of raw milk and its super-
vision by the government suggests the reminder
that certified milk is the standard by which all
grades are judged. Being raw and certified by
a medical milk commission under very rigid re-
quirements of law, it affords the utmost security
in this most important article of human food and
is indispensable for infants. The Essex County
Medical Society reiterates its frequent action re-
commending certified milk, not only because it is
raw but because its purity is unaltered by any
process in any respect.”
After the local business was completed, the
meeting was turned over to Dr. A. J. Ward,
Secretary of the Morris County Medical Society,
who presided and introduced the speaker, Dr.
William H. Ross, President of the New York
State Medical Society. After the reading of Dr.
Ross' paper, Dr. J. B. Morrison read one on the
“Possible Advent of State Medicine”, and discus-
sion was carried on from the floor to a late
hour.
The combined meeting was considered a great
success and Essex felt honored by the privilege of
entertaining her neighboring societies.
Academy of Medicine of Northern New Jersey
Eye, Ear, Nose and Throat Section
E. LeRoy Wood, M.D., Secretary
Several patients with interesting conditions, and
reports of many instructive cases, were presented
at the meeting of the Eye, Ear, Nose and Throat
Section of the Academy of Medicine of Northern
New Jersey, 91 Lincoln Park, Newark, Monday
evening, February 9. The Chairman, Dr. J. Wal-
lace Hurff presided.
In the business portion of the meeting, the
chairman appointed as a nominating committee
Drs. Elbert S. Sherman, Henry C. Barkhorn, and
Dennis F. O’Connor.
The subject of the high price of eye glasses was
discussed and general disapproval of the increas-
March, 1931 JOURNAL OF THE MEDICAL
mg' costs was expressed. One instance was cited
where the ophthalmologist’s prescription for a
person of very moderate means, with a small re-
fractive error, was filled by glasses costing $5 0.
This must work to the disadvantage of patients,
because they* cannot then afford the ophthalmolo-
gist’s supervision sufficiently frequent. The routine
urging by the optician of the more expensive
lenses, such as Punktal, Orthogon, and Tillyer, for
patients with small refractive errors, is likewise
condemned because unless the prescription calls
for a lens of 5 diopters or more, there is a
negligible difference between the expensive lens
and the ordinary lens. It was also mentioned
that very serviceable frames can be supplied, of
gold filled material, making the added expense of
the solid gold and the highly decorated frames
unnecessary. Drs. O’Connor and Sherman sug-
gested that a committee be appointed to study
and discuss the optical question. A motion ,vas
passed to that effect.
Dr. A. Russell Sherman, of Newark, who re-
cently returned from an extended visit abroad,
described in a very practical and interesting man-
ner the Eye Clinics in Vienna, Austria; his com-
plete paper Will be published in the Journal at
some future date.
In the clinical portion of the meeting, Dr. Lee
W. Hughes showed 2 patients. The first, a man
from whom he had removed a retrobulbar tumor,
giving the following description: This patient
came to my office on October 3, 1930, complain-
ing that there had been a protrusion of the left
eyeball for past 7 years and shortly after the
condition was noted he consulted a physician.
Radiographs were taken and a tumor mass local-
ized behin’d the left eyeball and to the outside.
An operation was advised but refused. The con-
dition had grown progressively worse and tumor
had increased to almost twice its size. Patient
stated that whenever he lifted heavy objects or
leaned forward there was a further protrusion of
the eyeball, sufficient to cause him great annoy-
ance, and he feels that he is unable to pursue
his occupation, which is that of a mason. He re-
quested that an operation be performed. No his-
tory of injury; had always enjoyed good health.
Married, and father of 7 children all well and
healthy. No history of eye trouble in family.
Vision O.D. 20/20; O.S. 20/200. There was a
marked proptosis of the left eye which was prac-
tically 1/3 out of its socket; eyeball appeared
to be fixed and stationary. The anterior struc-
tures were healthy; cornea clear; pupil round,
regular, reacted to light and accommodation.
General fundus was negative. Field of vision
normal. Upon light palpation a tumor growth
could be distinctly felt and this appeared to be
in the upper and outer part of the orbit and ap-
parently fairly adherent tio the superior and
lateral walls of the orbit.
Retrobulbar tumors are usually slow in growth
and are to be differentiated from orbital cellu-
litis or acute inflammatory ^processes by the
absence of swelling or edema of the structures
surrounding the eyeball. Even though the move-
ments are greatly limited or even immobile, there
is a gradual stretching of all the muscles and
tissues attached to the eyeball so that sometimes
useful vision is maintained. In slow growing
tumors there is stretching of the optic nerve so
insidious that no changes are noted upon exam-
ination of the fundus. There is usually marked
proptosis, depending, however, upon the size and
location of the tumor. In deeply situated tumors
SOCIETY OF NEW JERSEY 273
the external orbital wall must be removed to gain
free access to the orbit, and the operation of
choice is the so-called Kronlcin operation.
This patient was operated upon October 7, 1930,
at the Newark Eye and Ear Infirmary, under
local anesthesia (novocain adrenalin solution).
The Kronlein-Kocher incision was used — a curved
incision extending from the junction of the middle
and inner third of the brow downward to the fold
of skin approximately 10 mm. from the outer
canthus, and then continued toward the temple
for a distance of 3 to 4 cm. The tissues were
separated down to the bone and the upper arm
of the zygomatic bone was removed. The peri-
osteum of the orbital cavity was incised above
and below to allow free separation of the tissues
of the outer wall of the orbit, being careful not
to cut any of the muscular attachments of the eye-
ball. The tumor was readily outlined and by
Anger dissection was removed from its attach-
ment. Following removal of the tumor the eye
receded into the orbit in the normal manner. The
muscles were approximated by 00 catgut and skin
edges sutured with fine silk. The wound was
closed tightly.
There was considerable swelling of orbital tis-
sue following operation and on the fourth day
patient was discharged and told to report to the
office for further treatment. On the tenth day a
hematoma was opened in the brow and a large
amount of blood evacuated, and 10 days later
the wound had firmly healed. Four weeks from
the operation patient was able to read 2 0/20 in
left eye. The last examination made on January
27, 1931, vision was 20/20 in each eye without
correction. No diplopia with or without red glass
when fusion is broken; 12° esophoria distance;
1° right hyperphoria distance.
The tumor was sent to the laboratory and the
following measurements given: Length 39 mm.,
breadth 2 6 mm,, depth 22 mm. Sections made and
decription given: tumor is composed of many di-
lated blood vessels filled with blood and lined by
inactive endothelium. There is a considerable
amount of fibrous tissue stroma which appears
to take part in the tumor formation. No evidence
of malignancy.
Diagnosis: cavernous fibro-hemangioma.
Dr. Hughes presented his second patient hav-
ing the interesting condition, keratoconus, as fol-
lows:
This patient came to my office on December
3, 1930, with a request fj-om the United States
Veterans’ Bureau for an examination of eyes,
ears, nose and throat. The patient stated that
he was discharged from the Army in 1919 and
was then told that he had a cataract in the right
eye. Realized that the vision was poor at that
time but since the vision in the left eye was prac-
tically normal, and the right eye did not cause
him any annoyance, he did not seek further medi-
cal advice, taking as final the statement of the army
doctor that nothing could be done to improve
the vision in the right eye. He has been working
as a night watchman and ha^ experienced little
difficulty in attending to duties. However, during
the past 3 or 4 years he has been complaining of
headaches (especially in the region of the tem-
ples), some difficulty in nasal breathing. General
health has always been good; has never had any
operations; family history negative so far as eye
diseases are concerned. Vision: O.D. counts
fingers at 4 ft. O.S. 20/50. The conjunctiva of the
right eye showed a mild catarrhal inflammation.
Cornea was conical in shape and the apex of the
274
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
cone was situated just below and to the outer
part of the center of the cornea with a small
opacity at the apex of this cone which appeared
like a bleb formation. The left eye showed a
mild catarrhal inflammation of the conjunctiva
with a beginning conical cornea. I was unable to
obtain a view of the fundus of the right eye, but
examination revealed approximately 2.75 diopters
of myopic astigmatism, which corrected did not
improve the vision. Examination of the left eye
revealed 3 diopters of myopic astigmatism which
corrected the vision to 20/3 0. It is my impres-
sion that there is a higher degree of astigmatism
in the cornea of the right eye than that noted by
the keratoscope.
Keratoconus. The central part of the cornea
very gradually and without inflammatory symp-
toms begins to bulge forward in the form of a
cone. At first the cornea is perfectly transparent
and its peripheral portions keep their normal
curvature, but with a continual bulging of the
cornea the apex of the cone becomes opaque with
an uneven surface.
Keratoconus first makes itself apparent to the
patient by disturbance of vision. The eye be-
comes myopic but there is usually astigmatism.
It is a rare disease which as a rule affects both
eyes, beginning usually between the twelfth and
the twentieth year and very gradually in the
course of years coming to a standstill. There is
no increase of tension; neither is there ulceration
or rupture of the cornea. A keratoconus of slight
degree may be easily overlooked, since the cornea
is transparent, and where there is even the slight-
est suspicion of this condition the cornea should
be carefully examined by Placidios keratoscope.
The corneal reflex is irregular in outline and the
apex of the cone is not usually in the center of
the cornea but somewhere below it.
Treatment is very unsatisfactory. Where the
patient has been under observation for some time
and we are satisfied that the condition is station-
ary, it is best to content ourselves with a cor-
i ection of the refractive error, which is usually
a moderately high degree of myopic astigmatism,
bj concave spherical glasses alone or in combina-
tion with a cylinder. In certain selected cases
improvement of vision is secured by the use of
discs with stenopeic holes or slits, the size and
shape of these to be determined by examination.
Certain men have operated for conical cornea
but the results have only been imaginary and not
convincing either to their patients or their fellow
practitioners.
Dr. Dennis F. O'Connor described in detail per-
sistent pupillary membrane and showed patients
with the condition.
Dr. Andrew Rados showed a patient who had
i ecovered, with good vision, from sympathetic
ophthalmia following enucleation of the other
eye. The opportunity to examine this patient
was most valuable,
Di. E. A. Curtis read the following description
of Infantile Tay-Sachs Disease, an example of
which he had recently seen in one of his patients
m the Newark City Hospital.
In 1881 a case was reported by Dr. Tay with
the title, ‘ Symmetric Changes in' the Region of
Macula in Each Eye of an Infant”. In 1887, Dr.
Sachs reported a case of blindness 'associated with
idiocy, entitled ‘‘Arrested Cerebral Development”.
Mne years later he also recognized the familial
elements in the disease in another case, and gave
it the name of ‘‘Amaurotic Family Idiocy”. These
diseases occur between the age of infancy and 35
5 ears. The different varieties are infantile, juve-
nile, and adolescent.
Case Report
Hebrew boy, 13 months old, normal delivery,
full term, weighed 8 lb. at birth; parents not blood
relations. The child was admitted to the Newark
City Hospital on October 25, 1930, weighing
23 lb. Since birth the child has been back-
ward, took no notice of its surroundings, and
did not appear to see or hear. He began to have
convulsions 2 weeks before admission. During
these attack? he became cyanosed, with toxic
spasm of both hands lasting 3 to 4 minutes. He
had 10 or 12 of these in all. During these last
2 weeks, the child had changed perceptibly. While
in the hospital, he would lie quietly with no re-
action to any of his surroundings. He was a
well-developed, normal looking child. When
placed upright, he would fall over in any di-
rection. The anterior fontanelles would admit 1
finger, and the posterior fontanelles were closed.
There was a paralysis which was flaccid. The
reflexes were deficient. A fast pulse but the heart
was normal, and his chest was normal. No gland-
ular involvement, and no bone tenderness. The
urine was negative. No nystagmus and no stra-
bismus. Temperature ranged from 98° to 105°.
Died October 30, 1930.
Memorial Tribute to Dr. Charles J. Kipp
E. LeRoy Wood, M.D., Reporter
Leaders of the medical profession in North
Jersey met at the Newark Eye and Ear Infirmary
Sunday afternoon, January 18, to pay tribute to
the memory of Dr. Charles J. Kipp, Founder of
that institution, who died 20 years ago — January
13, 1911. Mr. Edgar Heller, President of the In-
fiimaiy, presided at the simple exercises in which
representative speakers recalled Dr. Kipp's ser-
vices to the community.
On the program were Drs. Edward J. Ill, of
Newark; Norton Wilson, of Elizabeth; John F.
Hagerty, Medical Director of St. Michael’s Hos-
pital; Frank W. Pinneo, Secretary of the Essex
County Medical Society; and Wells P. Eagleton,
Medical Director of the Infirmary. Each of the
speakers had been a friend and colleague of Dr
Kipp.
With Dr. Wiliam R. Rankin, Dr. Kipp GO years
ago founded the first eye and ear clinic in New-
ark, at St. Michael's Hospital. He was credited
with being the first to describe manifestations of
abscess of the brain in the eye, and the influ-
ence of malaria on the eyes. In addition to found-
ing the infirmary, Dr. Kipp was closely associated
with the late Dr. Henry L». Colt in the establish-
ment and development of Babies Hospital, Colt
Memorial, and with others in planning the New
Jersey State Sanatorium at Glen Gardner. Mt.
Kipp, near Glen Gardner, was named in his mem-
ory. Dr. Kipp was active also in the origin of
the Society for Widows and Orphans of Medical
Men, the Journal of the Medical Society of New
Jersey, and the Medical Library Association of
Newark, now the Medical Library of the Academy
of Medicine of Northern New Jersey. The build-
ing ot the Newark Eye and Ear Infirmary, a
monument to Dr. Kipp’s vision, was built from
contributions of Robert T. Ballentyne, Frederick
Frelinghuysen and J. William Clark. When the
March, 1C 31
joyrnal of the medical society of new jersey
275
clinic from which it grew was started in 18 80 by
Dr. Kipp, there was a budget of $750.
Dr. Edward J. Ill related from memory many
personal incidents, being acquainted with Dr.
Kipp from the time he came to Newark in 1868.
Dr. Norton L. Wilson paid the following tribute
to Dr. Kipp: “We are gathered here today to
do honor to the memory of one who established
this Institution and did much for the City of
Newark. Dr. Charles J. Kipp came to this coun-
try from Germany. He graduated from the Col-
lege of Physicians and Surgeons in New lrork in
1861. About that time the War of the Rebellion
broke out and he enlisted as a surgeon with the
Northern Army, serving faithfully and well. Those
of you who attended his funeral service will re-
member the tender words of Dr. John Wyeth,
who served in the Southern Army as a surgeon,
paying high compliment to Dr. Kipp, praising
Dr. Charles J. Kipp
his skill and devotion to the sick and wounded
not only of the Northern Army but also those of
the enemy. He related the story of Dr. Kipp
saving his life by his skill and devotion and they
remained staunch friends ever after.
I well remember when I first became associated
with him, at the old Infirmary on Sterling Street,
in 1885. He was then at the pinnacle of fame,
and was one of the foremost oculists in America.
He was a student and a dextrous operator. He
was exceedingly modest, and a man of few words,
which caused many to think him gruff, and yet
I have seen him as tender as a woman in hand-
ling a child. His contributions to medical lit'era-
ture were of the highest character. He never
married, but devoted his entire life to his pro-
fession. This institution was his child and he
gave of his means and very life that it might live.
He was the ‘old type gentleman’, never indulging
in excesses of any kind. He acquired a stoop in
his shoulders from his devotion to study; and
was somewhat deaf in one ear, which made him
sensitive in conversation. It was my good for-
tune to have served under him for a period of 8
years and during that time he was not only my
instructor but also my friend. May his memory
ever be cherished in our hearts.’’’
Dr. John F. Hagerty spoke as follows: “I deem
it a great privilege to represent St. Michael’s Hos-
pital at this splendid gathering of distinguished
men and women, assembled to do honor to the
memory of Dr. Charles Kipp, who was a mem-
ber of our Medical Board during the early years
of its organization- and who established there, 60
years ago, an Eye and Ear Infirmary, the first of
its kind in the state of New Jersey, and continued
its active and guiding force for many years. The
success and, indeed, the permanency of many in-
stitutions is largely dependent upon the start
which they receive, and St. Michael’s Hospital
was exceedingly fortunate in having for its spon-
sors and guides during its formative period a re-
markable group of men whose names are held in
grateful and reverent memory in many homes of
our city, not the least worthy among them being
the subject of this gathering. They were whole-
heartedly and devotedly interested in the welfare
of this young hospital, the second to have been
started in the state, St. Barnabas having preceded
it a very short time, and are, in large measure,
responsible for its successful continuance during
all the succeeding years. Dr. Kipp was so con-
vinced of the necessity for such an institution and
of the benefits to be derived from such a clinic
that he fitted it out with all necessary instruments
and apparatus at his own expense, some of which
are still in use at the present day. It is not easy
to put into understandable terms the value of
such interested and devoted lives as these, but
their successors are always aware of some in-
tangible force and stimulus which enable them
to carry on in sustaining their ideals. Dr. How-
ard Kelly said: ‘Even a cursory glance at the
deeds of the illustrious dead should encourage
those who are left to pass along the torch to
greater zeal in their daily tasks.’
I trust I may be permitted to refer to my own
acquaintance with Dr. Kipp. Soon after com-
ing to Newark I learned that he was one of the
outstanding figures among the medical men of
that day and, indeed, the most prominent of them
all. And I had not been long connected with St.
Michael’s before learning of his wonderful work
there and the indelible impress his talents and
skill had left upon that institution. I had the
good fortune later to become a member of the.
Medical and Surgical Society with which he was
actively identified, and can testify to the remark-
able influence he had upon every member of
the society. Upon hearing him talk one felt that
he was in the presence of a Master, of one pos-
sessed of abundant knowledge acquired by study
and travel and experience. He had a very direct,
lucid and convincing way of telling a thing, and
we listened when he spoke and were educated
and stimulated to aspire to higher and better
things.
I wish to thank Dr. Eagleton for his kindness
in permitting us to be here, and to compliment
him upon his thoughtfulness, not only in keep-
ing alive the memory of one whom I know he
reveres as his mentor and guide, but in helping
to perpetuate the beneficent influence of a good
name and an active and useful life. Pasteur,
the great French scientist, whose marvellous ac-
complishments w^re wrought during the life
period of Dr. Kipp, looked upon the cult of great
men as a principle of national education. ‘From
the lives of men w.hose passage is marked by a
trace of durable light’, he said, ’let us piously
gather up for the education of posterity, every
276
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
detail down to the slightest words, likely to make
known the incentives of their great souls.’
We are grateful for the opportunity of attest-
ing our high regard for the memory of Dr. Kipp
and appreciate the good that will result from re-
flection upon his life and work."
Dr. Frank W. Pinneo said: "Dr. Kipp was the
first President, and, only Life Member, of the
Medical Library Association of Newark. During
October 19 05 subscriptions ‘to establish a medi-
cal library and organize a Medical Library Asso-
ciation' had been secured by some personal soli-
citations and when these reached 130 names it
was suggested that an organization meeting be
called. The plan included the cooperation of Mr.
John Cotton Dana and the Trustees of the Pub-
lic Library in providing the place in the ser-
vices of trained librarians, while the Medical Asso-
ciation would hold possession of its books. Dr.
Kipp took such interest in the success of the
movement that he wanted the plan of this co-
operation assured before organizing, and when
informed this had been secured a meeting' was
held on November 18, 1905, and the Association
was formed. Dr. Kipp was, with universal ap-
proval, elected the first President and, the next
day, sent a check for the Life Membership fee,
thus becoming the first life member.
After organization of the Academy of Medi-
cine of Northern New Jersey and its possession
of a home, an agreement was negotiated, May 18,
1921, merging the 2 associations whereby the
property of the Library Association, accumulated
through the 16 years, with its cash balance as a
Library Endowment Fund, was transferred to
the Academy which agreed to ‘maintain, operate
and develop’ the medical library.”
Dr. Wells P. Eagleton, who has been Medical
Director of the Eye and Ear Infirmary since Dr.
Kipp’s death, read the tribute paid on that occa-
sion by the staff of the institution: “This insti-
tution was founded through his instrumentality
and he brought with him a body of personal
friends who undertook the work because they
were assured, by being associated in a beneficent
work with a man preeminently qualified by mag-
nificent ability and great nobleness of character.”
In the minds of those who knew Dr. Kipp the
memory needs no sustenance but the attention
of those who follow is directed to his character,
the ideals which he so nobly exemplified and his
life of generous service.
Following the service Dr. Eagleton entertained
the staff of the Infirmary at dinner at the Essex
County Country Club, West Orange.
Honor to Dr. Max Danzis
E. Leroy Wood, M.D., Reporter
More than 200 medical associates and friends
gathered at the Newark Athletic Club to pay
honor to Dr. Max Danzis, for many years
chief of staff of Newark Beth Israel Hospital.
Speakers dwelt on his long services to the com-
Tnunity and the aspects of his work that have
gone beyond the usual sphere of the physician in
social and scientific accomplishment. A framed
scroll containing resolutions was presented to
Dr. Danzis by the hospital’s medical staff, which
gave the dinner.
The speakers included'David I. Kelly, secretary
of the Essex County Park Commission; Frank I.
Liveright, president of Beth Israel; Dr. Nathaniel
C. Price, and Dr. Henry C. Barkhorn, who was
toastmaster. Dr. Danzis responded. Features of
the program were several piano solos by Rev. J.
Pierre Connor of Our Lady of Lourdes Church,
West Orange, and vocal solos by Paul Largay.
The arrangements were directed by Dr. Paul
Keller, executive director of Beth Israel.
At the speaker’s table also were Dr. Edward J.
Ill, Dr. and Mrs. John F. Hagerty, Dr. and Mrs.
H. J. F. Wallhauser, Mrs. Keller, Mrs. Barkhorn
and Mrs. Price.
The resolutions presented to the guest of honor
follow:
“Whereas, Dr. Max Danzis has served in the
capacity of founder, member and chief of the
medical staff of Newark Beth Israel Hospital and
has exercised his duties unselfishly and with great
efficiency as director of the medical staff of New-
ark Beth Israel Hospital, and
‘Whereas, Under guidance of Dr. Max Danzis,
Newark Beth Israel Hospital from a humble be-
ginning has reached a plane whereon it is one of
the leading medical institutions of the country.
Therefore be it
Resolved, That the medical staff of Newark
Beth Israel Hospital does hereby express its ap-
preciation of the unselfish services rendered to
this institution and to the community at large
by Dr. Max Danzis during his long years of ser-
vice; that the staff does further express its grati-
tude for the understanding and utmost patience
and unflinching fortitude with which Dr. Danzis
has ever performed such service; and be it
further
Resolved, That the staff hereby records its
appreciation of the quality and extent of the work
done under Dr. Danzis’ direction, and trusts that
it may continue to enjoy his just management for
many years to come.”
First Councillor District
Albert J. Ward, M.D., Reporter
Through the courtesy of the Essex County Medi-
cal Society, the First Annual Meeting of the First
Councillor District, comprising the County So-
cieties of Morris, Essex, Union and Warren, was
held in the Academy of Medicine, Newark, Thurs-
day evening, February 12.
The purpose of these joint meetings of the
county societies comprising each Councillor Dis-
trict in the State is to promote better acquain-
tance and understanding between neighboring
county societies, to strengthen and solidify the
profession, and so the State Medical Society, and
to advance medical practice.
About 150 members of the various societies
attended and the new undertaking was considered
a success.
The speakers of the evening were Dr. W. H.
Ross, President of the New York State Society,
and Dr. J. B. Morrison, Secretary of the New Jer-
sey State Society. Dr. Ross’ topic was, “A Way
to Avoid State Medicine”’. Dr. Morrison followed
this paper with one on “Some Phases of State
Medicine”. Both papers were enthusiastically re-
ceived, and lively discussion by Drs. Sommer,
Reik, Quigley, Hagerty, Lathrope, Beling,
Polevski, and other members followed.
The First District Councillor Committee wishes
to extend thanks to President Barkhorn and
members of the Essex County Society.
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
277
GLOUCESTER COUNTY
Henry B. Diverty, M.D., Reporter
The February meeting of the Gloucester County
Medical Society was held February 19, with a
large number of members present at the Hotel
Pitman.
The meeting took place in the form of a “round
table” discussion concerning the affairs of tl\e
society and an interesting discourse on the milk
question. Mr. TV. H. MacDonald, the acting chief
of the Bureau of Local Health, took the place
of Mr. D. C. Bowen, the State Health Director,
who was called to Washington, and proved a very
able speaker and held the attention of his lis-
teners throughout his talk.
The members present were Drs. S. F. Ashcraft,
I. W. Knight, W. J. Burkett, R. K. Hollinshed,
F. G. Wandell, E. E. Downs, C. F. Fisler, A. B.
Black, H. B. Diverty, Duncan Campbell, C. I.
Ulmer, B. A. Livingood, Wm. Brewer, H. M.
Fooder, C. A. Bowersox, Paul M. Pegau, Edwin
Ristine. Delegates included Drs. Miller and Ben-
nett, o7 Cumberland County; Dr. Oram R. Kline,
of Camden County, and Dr. Franklin Church, of
Salem County.
HUDSON COUNTY
E. G. Waters, M.D,. Reporter
The regular meeting of the Hudson County
Medical Society was held at the Carteret Club,
February 3, with Dr. J. M. Cassidy presiding.
The minutes of the previous meeting were ac-
cepted as published in the Bulletin.
The president reported for the Executive Com-
mittee, speaking of a letter received from the
Kings County Medical Society in reference to un-
ethical practices of the Hudson Clinic of Jersey
City, which has been referred to the State Board
of Medical Examiners for action.
Communications had been received from the
Gilbert Acceptance Corporation and were con-
sidered by the Executive Committee, with the de-
cision that this was purely an individual proposi-
tion and there was no reason to make it official
by the society.
The matter of re-zoning the city was discussed,
and its effect upon the location of physicians’
offices. The question is whether a physician is to
be considered in the same category as a business
man. The Executive Committee had recommend-
ed the plan of engaging a counsel to represent
the society whenever necessary.
The President spoke of the notice in the Bul-
letin requesting members interested in having
their names presented for an office, or as a mem-
ber of a committee, to sign the form and return
to the secretary. This was an opportunity for
every member of the society to come forward if
interested in doing any work. Up to the present,
the response has been practically negligible.
The resignation of Dr. Maurice Shapiro as
Chairman of the Publicity Committee was re-
ceived and accepted, and a new appointee is
to be named shortly by the President.
Dr. Edward G. Waters, as a member of the
State Committee on Post-Graduate Instruction,
asked concerning the plans of the local com-
mittee, as the State Committee was waiting to
hear of the plans of the local committee, and
thus avoid complication.
The revision of the Constitution was presented,
read article by article, and adopted.
A communication from the Hudson County
Tuberculosis League, inviting the membership to
attend a series of lectures on “Occupational Dis-
eases” to be held in Newark, was read.
Classified Advertising: Dr. H. C. Benjamin
stated that the Telephone Company had been
soliciting the profession to place an advertisement
in the classified section showing office hours and
specialties.
Dr. F. Quigley moved that the members of the
society should not participate in this until after
it had been considered by the Executive Com-
mittee. Dr. M. Swiney moved to amend that the
county society !s against such a practice.
Dr. C. B. Kelley wanted a definition of “medi-
cal advertising”. He stated that practitioners
not in the society would advertise. He advocated
the publication of a list of members of the Hud-
son County Medical Society under such a head-
ing.
Dr. I. L. Gordon stated that from the infor-
mation he had received only the office hours were
to be published, but suggested that we get a
definite statement from the Telephone Company.
It was incidentally mentioned that the classi-
fied list contained the names of other than reg-
ular qualified practitioners. Dr. Kelley stated
that the Board of Medical Examiners had taken
this matter up with the Telephone Company and
that it was cooperating to eliminate the names
of any but regular practitioners. Further dis-
cussion by Drs. Nelson and Perlberg. The amend-
ment of Dr. Swiney was lost; the motion of Dr.
Quigley was carried.
It was regularly moved and seconded that the
Secretary be authorized to notify the Telephone
Company to hold this matter up until it had been
sanctioned by the society.
Dr. S. Yachnin stated that some companies are
distributing lists of business and professional men
to apartment houses. Dr. IT. C. Benjamin moved
that the Executive Committee consider this mat-
ter. The' motion was carried. The members were
asked to send in any information concerning such
procedures to the Secretary.
Dr. F. McLoughlin spoke on the rule of the
American Medical Association that all hospitals
to be approved must have 20% of postmortems.
He stated that the undertaker stood in th s way
■ and suggested that this society take the matter
up with the Undertakers’ Association. It was
regularly moved and seconded that a committee
be appointed by the president to confer with the
Undertakers’ Association relative to this matter
and secure its cooperation in dealing with the
relatives of the deceased in an endeavor to limit
this conflict.
Dr. Cassidy stated that this is a very vital
question to those interested in hospitals and
therefore merits serious consideration.
Dr. W. Barbarito felt that it should be the
duty of the hospitals themselves to get together
and work out this problem. Dr. Nelson suggested
that the Secretary get in touch with the State
Society Secretary and have it taken up with the
State Undertakers’ Association.
Dr. Larkin believed that this is a local prob-
lem and that the County Board of Health and the
County Physicians should be asked to cooperate.
The following applications were received and
referred to the Board of Censors:
278
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
Drs. John L. Varriano, Jacob A. Riese, Samuel
A. Cohen, Henry C. Fattel, and Arthur Trewhella.
The following applicants having' been approved
by the Board of Censors were unanimously de-
clared elected as members: Drs. William F.
Schuchner, Benjamin Leavitt, Perry O. Hall, all
of Jersey. City, and Morris Green, of Weehawken.
Dr. Thomas White, reporting for the County
Committee on Post-Graduate Instruction, stated
that the program had been completed and was
to be given in conjunction with the State Com-
mittee. The 2 subjects were obstetrics and gastro-
intestinal diseases. They were to include lectures,
ward rounds, case illustrations, and obstetric
demonstrations, to take between 1 Ms and 2 hours.
The course was to be partially clinical, and was
to commence after Easter. The members to be
given further information through the mail. It
was regularly moved and seconded that this re-
port be accepted.
Scientific Program
Dr. Charles B. Kelley: “Gynecologic Thoughts”.
This symposium has been arranged at the re-
quest of our president, in furtherance of his ideas
that local talent can produce programs sufficiently
interesting to attract the membership of this
society. It has given me a great deal of pleasure
to help arrange this presentation, and I have
reserved for myself the introductory position in
order to outline to you just what our group has
attempted to do in carrying out the experiment;
whether noble or otherwise we will leave to your
judgment. At first glance, our program may ap-
pear extremely ambitious; perhaps it is. We have
arranged 6 papers which will be covered in very
little over an hour's time. Necessarily, only the
high spots can be touched by each essayist, but I
feel sure this will result in concentrated papers,
full of facts.
Gynecology is the mother of all abdominal sur-
gery. In 1809, Ephraim McDowell removed, for
the first time, a large ovarian cyst, and abdominal
surgery had its inception in a gynecologic opera-
tion. There can be no doubt, historically, that by
this operation McDowell earned for himself the
title of ‘‘Founder of Abdominal Surgery”. Not
only did he revolutionize the treatment of ovarian
cyst, which up to that time had simply been ab-
dominal paracentesis, but he demonstrated for the
first time the possibility of invading the peritoneal
cavity. The awe in which the peritoneum had
previously been held was dispelled and it was
not long before general abdominal explorations
had over-shadowed in importance the primary
gynecologic event.
As this is a symposium in gynecology it would
perhaps be well to define gynecology. Dorland de-
fines it as being that branch of medicine which
treats of woman’s constitution and diseases, es-
pecially of the genital, urinary and rectal tracts.
The definition is perhaps a little broader than
usually accepted although the ability to properly
diagnose rectal and urinary diseases is certainly
quite properly required of the gynecologist.
As my contribution to this symposium, I would
like to offer some general thoughts about gyne-
cologic diagnosis and in so doing I would em-
phasize the fact that gynecologic conditions, with
the exception of hemorrhage and ectopic preg-
nancy, are seldom urgent. Even ruptured ectopic
pregnancy is often best treated expectantly. The
term “acute surgical abdomen”, in the sense of
meaning immediate operation, seldom applies to
the female pelvis. Consequently, in the great ma-
jority of cases, the opportunity for careful study
is present.
The gynecologic history is of a fair amount of
importance, but the examination is of far greater
importance. A general, physical examination
should precede the strictly gynecologic one. This
does not have to be slow nor too detailed, but
should include listening to the heart and lungs
to rule out gross lesions and, of course, should
include an abdominal examination. It is well to
remember that heart disease often shows itself
as uterine hemorrhage.
A digital examination of the rectum and also
a proctoscopy are often very important, as lesions
of the rectum are often the etiologic factors in
gynecologic complaints. Many a dysmenorrhea
is due to an anal fissure and more than one retro-
verted uterus has been due to a redundant and
impacted sigmoid. I have seen many cases of
retroversion cured by properly given colonic irri-
gations.
Cystoscopic examination is often a big help,
and everyone doing gynecology should be able
to distinguish the ordinary bladder lesion. Empty-
ing the bladder before a vaginal examination is
important. A full bladder may easily be mis-
taken for a fibroid uterus.
Lumbar pain is due in many instances to causes
other than gynecologic, and it is always well to
exclude orthopedic conditions as etiologic factors
of a backache. Finding a retroverted uterus does
not necessarily mean that it is the cause of a
backache. More than one abdomen has been
opened for pain when the pathology was a tuber-
culous spine or a dislocated sacro-iliac joint. Bi-
manual vaginal examinations will be helpful
in finding pathology in many instances. It seems
unnecessary to say that every gynecologic ex-
amination should include the use of a speculum;
it is surprising that a different impression of a
cervix is gained through a speculum than is
obtained by digital examination.
In recent years, introduction of the insufflation
test of the fallopian tubes has been of great
value in cases of sterility. But even better- than
the gas test is the injection of iodized oil into
the tubes; a very reliable and permanent x-ray
record may be thus obtained.
A very important diagnostic aid is the curet,
as this instrument is of far more importance in
diagnosis than it is in treatment; and there is
a world of truth in that statement.
The laboratory is becoming more useful in
gynecologic diagnosis. Routine urinalyses and
blood counts have their spheres. The sedimen-
tation test is often a valuable diagnostic aid. The
Ascheim-Zondek test seems to be proving its
value in early diagnosis of pregnancy, which of
course makes it valuable in cases of suspected
ectopics. Basic metabolism readings become of
value in interrelated ovary and thyroid disturb-
ances. Biopsies and laboratory sectioning are
most important diagnostic aids.
I once heard John B. Deaver say that “when
all other diagnostic aids fail, there still remains
the aseptic scalpel”. Fortunately, in gynecology
we are getting further away from this philosophy.
Exploratory laparotomies are much less frequent
than they were. While the opened abdomen still
reveals some surprises, we have much more
larch, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
279
efinite pre-operative ideas of the pathology than
ormerly. Due to improved diagnosis, conditions
hat were once quite problematic have been re-
uced to a more definite basis.
This subject of gynecologic diagnosis might
asily use up the time allotted to the entire
ymposium, but the attempt of our group has
een to give you a real snappy program and con-
equently I am pleased to move along, well within
he time assigned me and to give way to those
rho are to follow.
“Noil-Malignant Lesion of the Cervix”
Dr. F. J. Quigley: Any consideration of diseased
conditions of the uterine cervix should be pre-
aced by that of the histologic structure of this
mportant portion of the female generative tract,
n thinking of the diseases to which it is subject
ve must ever bear in mind the fact that its lining
nueous membrane is abundantly furnished with
’lands the behavior of which, if infected or
:raumatized, is definitely characteristic. The endo-
:-ervix, especially, is equipped with a deep epi-
:helial layer in which are many compound race-
mose glands, normally secreting a considerable
amount of mucus. Under pathologic stimulation
;he output from these glands is enormously in-
creased. Should drainage also be defective —
tvhich is most likely to be the case — the condi-
:ions will favor the setting up of a chronic eon-
lition which will not be associated with a gland-
ular origin. Treatment will be directed toward
:he lesions presented by a condition of such long-
standing that its actual source may be ent’rely
iverlooked.
The commonly occuring inflammations of the
cervix of the uterus are customarily divided into
:hose which affect only the intracervieal mucous
membrane — endocervicitis — and those which take
place in the squamous epithelium of the cervix’s
raginal aspect, in its glands, its muscular struc-
:ure, or the entire lining mucosa of the cervical
canal, which we term cervicitis. These infiamma-
:ions are due in nearly all cases either to gonor-
rheal infection, or the entrance of some other or-
ganisms during parturition, or other manipulation
and trauma to the genital canal.
It is probable that trauma alone would seldom
bring about extensive inflammatory changes in
:he cervical mucosa. It is the practically inevitable
entrance of bacteria and their retention and
propagation in the glands, which lead to chronic
inflammation with eventual invasion of the deeper
structures, with the establishment of the wide
variety of pathologic conditions making up the
bulk of the gynecologist’s daily practice. The
necessity for prompt recognition of such a situa-
tion and its adequate treatment, should need no
emphasis. Cervicitis begins most often in simple
erosion. Viewed through the speculum, such an
erosion appears as an area of congestion upon the
vaginal aspect of the cervix, most often on the
anterior lip. Its salmon-pink color differentiates
it sharply from the normal tone of the surround-
ing mucosa. A section of the involved tissue will
sometimes present a rough surface with a partial
covering of columnar epithelium. If healing is
already well advanced, the surface will be rela-
tively smooth and a covering of squamous epi-
thelium be visible. In the follicular type of cer-
vical erosion, the involved glands in the deeper
tissues will have undergone a certain amount of
cystic degeneration, with infiltration by round
cells, polynuclear leukocytes and the prevailing
type of invading organism.
When cervicitis is due to gonorrheal infection —
less often if some other organism is responsible —
the immediate result of invasion is hypersecre-
tion from the racemose glands. When the infec-
tion has become chronic we have hyperplasia of
these glands, and this may later bring about
stricture or even complete occlusion of the cervi-
cal canal. With this interference with drainage,
the conditions for continuance of the infection
become even more favorable. The retained secre-
tions macerate the tissues, stimulating them to
greater activity, resulting in still further hyper-
plasia and the discharge of an even more exces-
sive secretion. The difficulties which are ex-
perienced in breaking the vicious circle thus in-
itiated are many, and vexatious to patient and
physician alike.
The use of local applications — ioain, nitrate of
silver, sulphate of zinc — has long been the regu-
lar gynecologic routine, followed by douching and
the insertion of tampons. In a certain percentage
of cases these measures relieved, or even cured
the patients. More often the effect was briefly
palliative, or wholly ineffectual. High amputa-
tion, which removed all the affected tissue, often
found favor, but in many instances the cure has
proved far worse than the original disease. Par
better is the Stur-mdorf procedure, which excises
the diseased glands but leaves most of the muscu-
lar structure. If we are faced with a condition of
long-standing, old tears with extensive scar tissue,
nothing but radical measures will be of any avail.
Operation thus becomes our only alternative.
Milder treatment, as by cauterization or dia-
thermy, has no place in such conditions.
The erosions following recent delivery, and the
cervicitis seen at this time, can often be well
handled by diathermy, provided they have not
been too long neglected. Heat treatment should
not be used if pelvic dellulitis is present, or in the
early acute stages of inflammation, particularly
that of gonococcal origin. In chronic gonorrheal
cervicitis diathermy is particularly successful.
This organism succumbs at a temperature of
113°. Within the cervical canal it is possible to
maintain a temperature of 116° to 118° P. with-
out the slightest discomfort to the patient nor
damage to the tissues, for a period of 40 minutes
or more. The indications for use of this agent
are, however, too limited to permit its very gen-
eral employment in the routine treatment of
cervical infections.
For the majority of cervical, conditions some
form of cauterization will prove most helpful, but
one must select with considerable care the type
of lesion to be dealt with in this way. It must
be kept in mind that external treatment is sel-
dom enough. Frequently the endometrium is
diseased all the way from the internal to the ex-
ternal os. Under such circumstances only deep
cauterization, after careful dilatation, will be of
any lasting benefit. For that large group of women
presenting conditions too well established to be
wiped out by local applications, but not sufficiently
.serious to call for the Sturmdorf or other operative
intervention, the Dickinson cauterizing method of-
fers the most efficient aid. Some gynecologists
of wide experience do not favor the idea of re-
peated slight cauterization, feeling that a single
deep application is more logical and generally
effective. I am of the opinion that the operator’s
professional judgment must be the guide. Each
case must be individualized. The only general-
280
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
ization possible is that, the longer the condition
has been present the deeper will the infiltration
of the tissues be, and, consequently, so much more
drastic will be the measures required for their
eradication. Graves, of Boston, not long ago told
me that he seldom applies the cautery more than
once, depending upon the thoroughness of this
single treatment to bring about abatement of the
glandular infection.
Dickinson's technic aims to produce an in-roll-
ing of the inflamed lips as scar formation takes
place, stricture of the os being thus avoided. This
is important in women who can be expected to
bear more children. Using a cautery outfit simi-
lar to that employed in nose and throat work, a
fine platnium tip burns “tiny gutters’’ about V4, in.
apart. If only small areas are eroded it will be
sufficient merely to puncture the affected tissue
at frequent intervals. This treatment is repeated
at intervals of about 2 weeks. If cystic degenera-
tion of the glands has taken place, the fine cau-
tery will open up the cyst, a tenaculum holding
open the canal so that it can penetrate to the
very lowest depth reached by the disease. This
method has many advantages, and if prop-
erly used will save the great majority of
women suffering from cervical inflammation the
strain and expense of surgical interference.
General anesthesia may at times be neces-
sary, but in the average office patient it can
usually be dispensed with. It is important to
have the canal thoroughly dry before the cautery
is applied. Too great heating of the tip is likely
to cause bleeding, which interferes with operator
and operation alike. Though a description of the
method sounds simple enough, as many other
things outside the practice of medicine as well as
in it, practice is necessary in or- or to obtain the
best results, and it is only by experience that one
can learn exactly when and where to apply it.
Because cervical infection is such a common
finding, and the presence of a discharge is taken
as so much a matter of course by* the majority of
gynecologic patients, we are often prone to over-
look its importance. Anything that interferes
with free drainage from the genital canal is of
gave consequence, and a disregarded benign les-
ion may eventually lead to something quite
beyond hope of any aid from us. There is
impressive evidence that the pathologic cer-
vix may serve as a focus of infection quite
as virulent as tonsil, appendix or gall-bladder
when similarly invaded by bacteria. The re-
lation of birth trauma and other injuries of the
cervix to malignant disease, has been too widely
discussed to make it necessary for me to dwell
upon it. The routine care of such lesions is tire-
some and, apparently, often unprofitable both
spiritually and financially. But as a measure of
preventive medicine and a step toward the con-
trol and eradication of one of the greatest afflic-
tions of womanhood, it immediately assumes
dignity and consequence — something quite worthy
of our best efforts and highest professional skill.
Dr. Margaret Sullivan Herbermann : “Acute Pel-
vic Lesions.’’ In early and accurate diagnosis of
acute pelvic lesions, one must have in mind 2 out-
standing thoughts: (a) The conservation of life,
(b) The importance of conserving, as much as
possible, the function of the pelvic organs. Be-
cause of the future comfort and welfare of the
patient, avoid unnecessary removal of the pelvic
organs, the early artificial menopause, with sub-
sequent suffering and neurosis and the arresting
of the child-bearing functions. These factors have
great influence on the patient's future. In cases
where surgery is indicated, it is important that
an early diagnosis should be made without loss
of time because: (a) Hemorrhage may take un-
due toll, (b) Sepsis may have made such progress
as to seriously damage the patient’s chance of
either life or complete restoration to health.
Acute pelvic conditions should, therefore, be
classified into surgical and nonsurgical. Surgical:
(1) Septic abortions. (2) Ectopic pregnancy. (3)
Tumors having twisted pedicles — either fibromas
or ovarian cysts. (4) Accidental perforation of
the uterus. Nonsurgical: (1) Septic abortions;
no curretage where there is fever or sign of per-
itonitis. (2) Acute puerperal sepsis. (3) Acute
salpingitis.
Development of sepsis requires time between
the implantation of septic contamination and the
picture of septicemia — the interval depending
upon: (1) The invading organism. (2) Resistance
of the patient. (3) Site of the septic implanta-
tion. Such interval is longer in the pelvis than
in the upper abdomen. Gonorrhea is the exciti-g
factor in most cases.
Most seriously infected cases have followed pre-
liminary instrumentation, and infection rarely
follows a single invasion of the uterus, but usually
follows repeated instrumentation.
Dissemination of infections occurs chiefly
through the walls of the uterus and frequently
begins at the site of the placental implantation.
Pelvic cellulitis resulting from such infection
should, if treated by surgical means, delay oper-
ations from 6 months to 2 years. Indications for
surgery: (1) Persistent pelvic pain with disten-
sion1, some rigidity. (2) Functional bleeding. (3)
Chronic ovarian abscess. (4) Inflammatory masses
which arrest function or menace health. (5)
Chronic intestinal obstruction due to pressure of
inflammatory processes on intestinal tract.
Pelvic peritonitis associated with acute salp-
ingitis is treated upon expectant lines. Except
when a definite abscess forms, which should be
drained through the cul-de-sac, salpingitis should
be treated conservatively. It usually localizes and
the child-bearing function may ,be preserved.
Even if there is doubt about the diagnosis, it is
far safer to make an incision and retire without
further interference. Mayo says he has seen many
cases die when no exploratory has been made, but
he has not seen any one die as result of an ex-
ploratory operation.
Dr. James L. Cobham: “Early Diagnosis of Pel-
vic Infections.’’ The fact that pelvic malig-
nancies are usually unattended by pain in their
early stages places upon the physician a
grave responsibilty. When symptoms have arisen
which justify the classification of cancer, as such,
a favorable prognosis may be considered ex-
tremely doubtful. On the other hand, the stage
of the disease in which treatment is instituted is
a prime factor influencing prognosis, as it is
well recognized that the average period of ex-
tension of malignancy beyond its localized limi-
tations is only from a few weeks to a few months.
The task of the physician is further compli-
cated by the fact that cancer is often superim-
posed upon a noncancerous condition at some
site of chronic irritation or a benign tumor; in
fact it may safely be said that the earliest symp-
toms of cancer are really those of the precan-
cerous condition itself.
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
281
In considering malignant disease of the female
generative organs, carcinoma of the cervix is, by
far, the most frequent type with which we have
to deal; this has been ably shown by Ewing in
his studies of 8 55 8 cases of malignant tumors in
Women at Memorial Hospital covering a period of
12 years. He found cervical cancer ;n 2134 in-
stances, or 24.9% of the entire group, while car-
cinoma of the body occurred in only 233, or
2.61%, of the entire group. Malignancies at these
2 sites differ widely in etiology and behavior; nor
does the age incidence correspond; carcinoma of
the cervix is most frequently seen in women who
have borne children and are between 40 and 50
years of age, while that of the fundus occurs at
the average age of 55 and in those who are single
or have had a sterile marriage.
For practical purposes, an accurate diagnosis
of the extent of cervical cancer is of prognostic
importance and Greenough has set a standard.
(1) Where the disease is limited to the cervix — -
prognosis good; (2) extension to the uterine body
or vaginal wall; (3) to the broad ligament; (4)
widespread, producing extensive pelvic fixation
and involving bladder, rectum, lymph-glands and
even remote organs.
The early symptoms of cervical malignancy are
so general that the physician, as well as the pa-
tient, may be entirely unsuspecting. A suspicious
symptom is leukorrhea with intermenstrual bleed-
ing. Do not wait for pain because, as a rule,
when this appears the disease is too advanced for
cure. The initial vaginal discharge may not dif-
fer from ordinary leukorrhea, except in quality. It
soon, however, assumes a watery consistency,
characteristic of cancer, and should lead to a
thorough examination of the patient. At a later
stage, the discharge gives evidence of infectious
decomposition and is of a foul odor. Small, bluish
white, glazed nodules are often seen on the in-
durated cervix. Another important diagnostic
sign is intermenstrual bleeding due to trauma of
the eroded cervix in ordinary muscular move-
ment, or during coitus or digital examination. In
the advanced stage, the diagnosis is most obvious
and needs no mention. Leukorrhea, menorrhagia,
metrorrhagia, and the eroded hypertrophied cer-
vix demand a microscopic examination by biopsy.
Some men oppose this but the concensus of opin-
ion agrees with Greenough that biopsy is safer
than delay. There are several conditions that
simulate cancer of the cervix and, among them,
are deep-seated Nabothian cysts, chronic cervi-
citis, tuberculosis, syphilis and sarcoma. Here,
again, the importance of biopsy cannot be too
strongly emphasized.
Prophylaxis against cervical cancer deserves a
word. Since one of the impulses that start cel-
lular activity upon its wild ungoverned growth
is conceded to be some sort of chronic irritation,
it is obvious that removal of abnormal friction
and repair of conditions, causing mechanical or
chemical irritation, cannot be overlooked. In this
connection, I mention infected leukorrheal dis-
charge, malposition of the cervix, ncomplete
drainage from the genital canal and repair of
traumatisms after child-birth.
In the majority of cases, the symptom pointing
to cancer of the body of the uterus is spotting
of a pinkish, or crimson hue after the menopause.
In addition, a profuse watery discharge is usually
present. Before menopause, a symptom may be
menorrhagia or metrorrhagia. As in cervical
cancer, pain is not evident until the disease is ad-
vanced. As in cervical cancer, too, the final diag-
nosis can only be made with the microscope.
Since the uterus may be completely invested with
cancer but retain its normal size, the sense of
touch is of little diagnostic value. A warning note
may be sounded here that, since corpus cancer ex-
hibits a strong tendency to seed implantation,
manipulation, in curettement of the uterus for
a biopsy specimen, should be exceedingly gentle
so as not to force cancerous material, if present,
into the fallopian tubes.
(Sarcomas, originating in the cervix or body of
the uterus, are fortunately rare, and, when they
do occur, the early symptoms are very similar to
those of cancer; especially so, the diffuse variety,
and the diagnosis can only be made with the mi-
croscope and curette; even this may fail if the
endometrium is not involved. By the time the dis-
ease exhibits its grapelike, polypoid mass from
the cervix, or the finger detects the soft, smooth
growth on the endometrium of the uniformly en-
larged softened uterus, or bimanual examination
reveals the hard nodules of fibrosarcoma, the dis-
ease is beyond control.
Carcinoma and sarcoma of the ovary, in their
early stages, have no distinguishing features,
from benign growths except earlier onset of pain.
Ewing found carcinoma to have occurred in 1.88%
of his entire group and the age period varied
from 5 years to 6 5. Unfortunately, when most
of these cases are seen, it is too late, due to the
early and extensive metastasis. Any woman pre-
senting herself, complaining of pain, with any
alteration in the menstrual cycle, and enlarged,
tender adnexa, should be regarded as a possible
malignancy.
Dr. John B. Faison: “Therapeutics of Pelvic
Malignancy”. The purpose of this paper is to
summarize, as briefly and concisely as possible,
the present status of the treatment of pelvic
malignancy with particular reference to cancer
of the cervix and body of the uterus.
Roughly speaking, 25% of all carcinomas that
afflict the female occur in the uterus and, unfor-
tunately, cancer incidence is steadily increasing.
Almost all of us are called upon, at some time
or other, to face the problem of what to do for
a patient with uterine cancer, and at such times
our first thought is naturally what wlil give this
woman her best chance for survival. And this is
often no easy question to decide for it involves
many factors: the nature of the growth; extent of
the disease; condition of the patient; and most
vexing of all, the, procedures to'be followed — sur-
gery or radiation, or both. Obviously, all carcino-
mas of the uterus are not alike in their cellular
make-up, nor are they encountered at the same
degree of advancement, and since the results to
be expected from any form of treatment depend
almost entirely upon these variations we must
consider them closely before a prognosis can be
made. It is now the practice to try to place these
neoplasms clinically under 1 of 3 heads, namely,
early, border-line, and advance. In carcinoma of
the cervix the early group is composed of cases in
which the malignancy is localized to the cervix.
The border-line cases are those showing slight
extension into the tissue about the cervix, with
moderate fixation of the cervix but a freely mov-
able uterus. The advanced group comprises those
cases in which there is wide extension in all
planes with complete or almost complete loss of
mobility.
In carcinoma of the body the gradation is an-
282
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
alogous except for the added factor of uterine
enlargement.
Our next consideration is the histology of the
growth. It is a well known fact that cancerous
growths of the uterus, even though discovered
in an early stage, may show widely different de-
grees of response to treatment in different in-
dividuals. Allowing for the so-called personal
factor, why should this be? The answer lies in
the cellular make-up, or histology, of the tumor.
The lining epithelium of the corpus uteri is
columnar celled and malignant growths of the
body are almost invariably adenocarcinomas. I
am purposely omitting reference to sarcoma and
chorio-epithelioma which are exceedingly rare
forms and are almost never seen by most of us.
These cancers are relatively slow growing and
are fairly uniform as to rate of growth. The lin-
ing epithelium of the cervix, on the other hand,
is almost entirely squamous celled and unlike the
body there are- widely marked degrees of cell pro-
liferation and malignancy. This fact has been
recognized by pathologists for years but it is
only recently that its significance with relation to
treatment and prognosis has been realized. It is
on these histologic variations that Broders, of the
Mayo Clinic, and Ewing, of the Memorial Hospi-
tal, have based their gradations of squamous
cell carcinoma. Dr. Ewing’s classification, which
is most commonly used in and about New York,
recognizes 3 grades based upon the degree of
anaplasia of the tumor and by anaplasia is meant,
in brief, collularity, variations in shape and size
of nuclei, tendency to infiltrate, number and qual-
ity of mitotic figures, and absence of adult cell
characteristics.
At one extreme there is a small group (about
17% of total) showing tumor cells closely ap-
proximating the adult normal cells and with
marked squamous tendencies, which he calls
Grade 1 or Adult type. At the other extreme is
another slightly larger group (21% of total)
where the cells have lost all differential character-
istics and show marked powers of proliferation
and infiltration; the anaplastic and highly malig-
nant form. In between, is a larger group (ap-
proximately 62%) which shows characteristics in-
termediate between the extremes and which is
called the “plexiform type”. The great impor-
tance of this histologic classification, upon the
prognosis and mode of treatment, will, I hope,
become apparent as we go on.
Now as to treatment. First, let us consider
carcinoma of the corpus uteri. As has been said,
it is much less frequent than carcinoma of the
cervix; about 1 out of 10 cases of uterine malig-
nancy occur in the body. It grows relatively
slowly, spreads first by direct extension to the
parametrium and involves the lymphatics later.
For these reasons it is usually considered to be,
in favorable cases, primarily a subject for sur-
gical attack. My own feeling is that, except in
very early cases, it should be treated by com-
bined radium and surgery. Cancer being what it
is, it behooves us to give our patients every pos-
sible chance for recovery and thorough irradia-
tion of the uterus before operation, with maxi-
mal possible tumor destruction and lymphatic
blockage, certainly seems to be a safer and more
reasonable procedure than surgery alone. The
morbidity from treatment is slight and if 2 to 3
weeks are allowed to elapse before operation, the
technical difficulties for the surgeon are enhanced
very little, if any. Late cases, which are in-
operable, leave us no choice. Here, radium and
deep x-ray therapy, as palliative agents, are
generally regarded as the only therapeutic means
at our disposal. The treatment of carcinoma of
the cervix presents quite another problem. Here
we have marked variations in tumor histology to
consider as well as the degree of extension of
the disease. And this is where the pathologist's
gradation is of vital importance.
Recent work at the Memorial, in New York, has
shown a distinct relationship between the cel-
lular structure of a tumor and its response to
radium or surgery. In other words, the more
anaplastic or malignant the growth the greater
its sensitivity to radium and the more prompt
its recurrence following surgery. Conversely, the
less anaplastic and the more adult the cell type
the greater its resistance to radium and better
the results from operation. In other words, the
point I am trying to make is this, we must know
accurately not only the extent of disease but also
the histologic nature of any cancer of the cervix
before we can know how to serve the best interests
of our patient. And what is best for the patient
with this disease? To my mind the answer is
definite — complete and thorough irradiation — and
the easiest way to prove this contention is by
comparing the end-results of surgery and rad-ium.
Dr. Wm. P. Healy, Attending Gynecologist to the
Memorial Hospital, has kindly allowed me to
use the following statistics taken from his ser-
vice for comparison with analogous groups re-
ported by the Johns Hopkins Hospital and the
Mayo Clinic. These figures represent 200 cases
of proved carcinoma of the cervix treated in
1922-23 by radiation as compared with the same
number treated surgically.
Radiation Surgery
State
Per Cent
Cured
J. H. H.
Per Cent
Cured 5 yrs.
Mayo
Clinic
Per Cent
Cured
Grade
I
Operable
50
47
53
Advanced
4
Grade
II
Operable
43
Advanced
14
24
21
Grade
III
Operable
66
Advanced
42
9%
9 V2
Analysis of these figures shows that only one
group (Grade I) 17% of total cases, is surgery
comparable to radium as far as end-results go.
In group II, the advantage of radium is
marked; in Group III (the highly malignant
type), it is overwhelming. In other words, sur-
gery at best has little to offer except in a rela-
tively small percentage of early and border-line
cases of the adult type. And even there, it offers
no advantages over radium in end-results and im-
poses a major surgical procedure and relatively
long hospitalization upon the patient besides.
In the highly cellular, malignant group radium
at times works almost miracles, with a record of
G6% 5-year cures in so-called operable cases and
42% cures in advanced cases as compared with
9 Vi % cures, obtained in early cases only, by the
most expert operators.
Therefore, since the histologic gradation of epi-
dermoid tumors has not yet been widely adopted
by pathologists over the country, and since sur-
gery even in properly selected cases imposes a
greater physical and financial strain upon the
patient, than radium, it is my belief that car-
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
283
cinoma of the cervix should be a problem for
radiation and radiation alone.
As for malignant diseases of other pelvic or-
gans, such as ovary and fallopian tube, suffice it
to say now that results with radiation alone are
not very satisfactory- Radium and the x-rays
have some value as palliative agents but our
main hope in these diseases is still early and
competent surgery.
By way of summary, we may say that:
(1) Cancer of the corpus uteri in early or
border-line cases is best treated by surgery, al-
though pre-operative radiation would seem to be
advisable if there is any question as to extent of
the disease. In late cases radium is useful for
palliation.
(2) Carcinoma of the cervix is preeminently a
condition for radiation and the results we may
expect from this method of treatment depend in
large measure uion (a) the clinical degree of the
d.sease — early border-line or advanced; and (b)
adult type and radio resistant, anaplastic type
and radiosensitive or intermediate type. These
factors, if kept in mind, may make a trifle easier
the approach to an unfortunately obscured and
complicated question.
Dr. Frank J. McLoughlin. “Importance of the
Pelvic Fascia in the Repair of Cystocele and
Rectocele.” Injuries to the birth canal resulting
in hernias of the pelvic tract. Fascia is to be
used in their repair as it is now being used in the
repair of other forms of hernia. Rectocele is
due to injury of the rectovesical fascia. There
are three layers to be considered. (1) The layers
of fascia on the 2 surfaces of the levator ani
muscle. (2) The triangular ligament. (3) The
rectovaginal fascia.
Dr. McLoughlin gave a lantern slide demonstra-
tion of the fascial layers and the development of
cystocele and technic of repair. This was fol-
lowed by a similar group of pictures depicting
rectocele development and repair. In conclusion
he stated, that since rectocele and cystocele are
essentially hernias, the available fascia should foe
used for their correction.
Bayonne Hospital Clinical Conference
Maurice Shapiro, M.D., Secretary
The regular meeting of the Clinical Conference
of Bayonne Hospital was held Monday evening,
February 2, at 9 o’clock. In the absence of Dr.
Donohoe, Dr. Sexsmith acted as Chairman.
Dr. Morgensteiru reported for the service of
Dr. Weiss. Case 1. Cardiovascular syphilis with
multiple aneurysms. A. C., aged 68, male, admitted
December 17 with swelling of right knee and in-
ability to walk. Three weeks prior to admission
knee began to swell tremendously and then could
not move knee at all; is mentally dull, very inco-
herent, and connected history could not be ob-
tained. Denies venereal history. Pupils did not
react to light, but did react to accommodation.
Low systolic murmer at apex; low diastolic mur-
mer at aortic area. Heart enlarged. In right
axilla there was a marked pulsation. Radial
and brachial arteries markedly tortuous and pul-
sating. Corrigan pulse at wrists. Right popliteal
artery greatly enlarged, and forming a pulsating
mass. Left knee swollen and painful over an-
terior aspect. Numerous varicosities in both legs.
B. P. 156/62. Wassermann and Kahn tests posi-
tive.
While in hospital general condition became
gradually worse; developed Cheyne-Stokes’ res-
piration, and expired on January 14.
Case 2. Chronic rheumatic endocarditis. Z. P.,
aged 26, admitted for last time on June 16, com-
plaining of difficulty and shortness of breath, ab-
dominal distention and edema of ankles. Present
illness began about 3 yr. ago with swelling of legs,
dyspnea on slight exertion, orthopnea, associated
with an intermittant non-productive cough. Was
sent to hospital at that time and condition im-
proved in a few weeks so that he was discharged.
A year later dyspnea and cough returned. Was re-
admitted to hospital and after a few weeks im-
proved and was again discharged. Some time
later gave history of having been struck in ab-
domen with a baseball and above symptoms again
recurred, and after another stay in the hospital
was again discharged as improved. Had several
more readmissions with same symptoms until
present time.
Heart very much enlarged; loud systolic mur-
mur at apex; fibrillation present. Lungs: moist,
crackling rales present at bases posteriorly, with
dullness.
Progress very unfavorable; developed marked
ascites, severe dyspnea,, became very despondent,
refused medication and went into a coma for
several days. Toward the end, became markedly
cyanotic and finally expired on January 25.
Case 3. Subacute endocarditis. E. M., aged 20,
female, admitted January 10 complaining of sore-
ness of right shoulder and swelling of right leg.
Influenza 11 weeks before and had been confined
to bed ever since. During this period she had
cough, chill, fever and dyspnea. About 2 weeks
prior to admission she got up from bed against
doctor’s orders, and soon began complaining of
pain in right ankle and knee joint. Loud systolic
murmur at apex transmitted to axilla; also mur-
mur over aortic area, systolic in time. Tempera-
ture from subnormal to 105°.
Blood culture showed Streptococcus viridin.
Given total bed rest, salyeilates and supportive
treatment. Still alive. Has periods when she
feels better but condition is practically unchanged.
Dr. Sklar, discussing the prognosis of bacterial
endocarditis, stated that text-books all claimed
a 100% mortality. However, at a recent confer-
ence at the Academy of Medicine, Dr. Emanuel
Libman presented several cases of cured subacute
bacterial endocarditis.
Dr. Antapol then told of the healing and of
healed subacute bacterial endocarditis cases which
developed glomerulonephritis.
Dr. Sexsmith questioned why so many children
should have rheumatic heart conditions at an
early age, proceed to grow normally without any
bad signs in spite of the fact that loud murmurs
are heard in the heart, and that at the age of 17
or 18 he finds no evidence of damage to the heart;
that in his opinion 90% of these cases get well
and show no after symptoms.
Dr. Antapol replied that in spite of rheumatic in-
volvement the individual may be compensated
and die of some condition other than rheumatic
involvement of the heart. There is also patho-
logic evidence of repeated acute attacks, one
superimposed on another. Cases have also been
observed in which at death no evidence of rheu-
284
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
matism was present, and yet Aschoft bodies were
found in the myocardium even though the last
clinical attack had been observed 17 years pre-
viously.
Dr. Fifer, service of Dr. Sexsmith, presented a
case of fracture of the femur with over-riding.
F. D. V, male, aged 19, was admitted November
12. Sustained an injury to left thigh in automo-
bile accident. Admitted to hospital immediately
after accident. X-ray examination then showed
an oblique fracture at the middle of the femur,
with a slight amount of over-riding, probably
about iy2 in.; lower fragment displaced inward
and backward. A Buck s extension splint was
applied. On December 1 — 19 days after admis-
sion— radiograph disclosed the fragments with
the same alignment, but the over-riding more
marked. On December 5, a spica cast was ap-
plied. Three days later, x-ray examination
showed the fragments to be in the same position
as previously reported; a very slight amount of
callus seen; an over-riding of at least 3 in. and
the lower fragment displaced inward and back-
ward. Buck’s extension apparatus was re-applied
with 24 lb. weight.
On December 22, a reexamination of the frac-
tured femur showed the fragments in about the
same alignment but the amount of over-riding
markedly diminished. The extremity was kept
in counter extension until January 20 — 9 weeks
after admission — and as there was still no evi-
dence of union an open reduction was decided
upon. Under ether an incision was made at the
outer side of the thigh through the skin and
superficial fascia, along a line from the anterior
superior iliac spine to the outer angle of the
patella. The external circumflex vessels and
nerve were retracted proximally upward, the
vastus intermedius was divided in its upper part,
and the shaft of the femur exposed. The ends
of the fragments were found to be over-riding
approximately ‘1% in., and covered with fibrous
tissues. There was no union between the frag-
ments. The line of fracture was at an extremely
oblique angle, which made it impossible to bring
the fragments together. An attempt was made to
sever the irregularity on the distal fragment, by
means of a Gigli saw, but without success. Ron-
geur forceps were then resorted to and the pro-
jections of bone on both fragments were pared
off. It was then possible, with the aid of counter
extension on the foot and leverage under the frag-
ments, to approximate the bones so that the
normal anatomic relationships, as in horizontal
and right angled planes, were restored. Upon ro-
tating the foot from side to side, the entire femur
now rotated with it. The deep muscle fibers, to-
gether with the retracted periosteum about the
fracture site, were then approximated with in-
terrupted sutures. No drains were inserted. The
skin incision was closed with interrupted silk-
worm gut. A plaster of paris spica was applied
from the pelvis to below the knee, with a window
at the site of incision. The patient’s immediate
postoperative condition was good. On the follow-
ing day he complained of considerable pain and
discomfort in sacral region. A cotton pad was
applied. Two days later, patient took it upon
himself to cut away cast from pelvis. Radiograph
showed fragments in much better alignment, as
compared to previous examination, but lower
fragment still showed a slight posterior displace-
ment.
The particular point of interest in this case Is
the lack of cooperation of the patient and the
amount of damage that can be done by a patient
of that type.
The Surgical Service also brought up a dis-
cussion as to the proper time for amputation in
traumatic injuries of the legs. The question is
one which has been under discussion for a long
time. Some authorities claim that the amputa-
tion should be done before the patient comes out
of his initial shock, while others say wait. Drs.
Sexsmith, Pinkerton and Chayse were all of the
opinion that the mortality in early amputation is
far greater than in later amputation. Dr. Chayse
brought out the interesting fact that in the war
most amputations were done anywhere from 1
to 3 weeks after the injury and that the death
rate was low. However, one must take into con-
sideration the fact that these men were young
and in good physical condition. In civilian life, we
have to deal with people of all ages and physical
disabilities and that there can be no set rule as
to when to amputate.
Dr. Eisner reported a case of subcutaneous
emphysema of the chest in conjunction with a
case of pneumonia on the service of Dr. William-
son. Patient entered January 16. Chief com-
plaints were cough, vomiting, chills and fever.
Duration of present illness was 1 day. Began with
slight “head cold”. The next morning, following
a severe vomiting and coughing spell, tissues
around the neck and upper thorax began to swell.
There were 2 soft cushion-like swellings of the
upper thorax and swelling involving the sub-
cutaneous tissue of almost the entire neck, face
and scalp, and downward the chest wall, ab-
domen and even thighs. It was impossible to
auscultate because of the crackling of air in the
tissues.
Dr. Pinkerton reported a case of papilloma of
of the vagina in a woman 29 years of age. There
was a cauliflower mass filling the vaginal en-
trance which appeared to be on the right labia
extending above the clitoris. This mass had the
appearance, grossly, of a malignancy. Wasser-
mann was negative. Biopsy was negative as to
malignancy but suggestive of lues. The mass was
removed and a broad fibrous base attached to the
labia was found. The base and mass were cut
away and the stump coagulated by surgical dia-
thermy.
MERCER COUNTY
A. Dunbar Hutchinson, M.D., Reporter
The Mercer County Medifcal Society met in the
Carteret Club on February 11, President Swern
in the chair. The usual order of business was
suspended, and the program taken up at once.
“Diagnosis and Treatment of Non-Tuberculous
Diseases of the Lungs’’ was discussed by 4 emi-
nent men from Philadelphia. Dr. Elmer H. Funk
defined in a most entertaining manner the clini-
cal symptoms. Dr. John T. Farrell, Jr., described
in detail the value of roentgenologic study. Dr.
Louis H. Clerf emphasized the importance of
bronchoscopy with lipiodol instillations. Dr.
George Willauer, speaking upon the surgical as-
pect, outlined in a general way the several heroic
measures employed.
The speakers confined their discussions to 3
March, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
285
conditions most frequently diagnosed; abscess
bronchiectasis, and new growth.
The applications of Drs. Harry J. Majeski and
Anthony J. Lettiere were read and referred to
committee. Drs. Vartan Kachdorian and Joseph
Ragany were elected to Associate Membership.
Dr. Little reported that the Post-Graduate
Course will consist of 3 subjects: Operative Gyne-
cology; Newer Therapy; and Pediatrics.
A report of the Committee on Public Relations,
relative to printed forms, explaining the value of
toxin-antitoxin to accompany birth certificates,
was read and the recommendations endorsed and
the committee authorized to confer with Plealth
Officer Alton S. Fell.
Dr. D. L. Haggerty gave a very interesting ac-
count of recent legislative action, urging on every
member the necessity of attendance upon hear-
ings that may be called.
Expressions of regret concerning the present
illness of Dr. C. J. Craythorn were attended by a
motion that a remembrance in the form of a
basket of flowers be delivered to him.
MONMOUTH COUNTY
W. Von Oehsen, M.D., Reporter
The monthly meeting of the Monmouth County
Medical Society was held at the Red Bank Yacht
Club, Wednesday evening, January 28, with Dr.
William K. Campbell presiding. Minutes of the
previous meeting were read and approved. Com-
munications were read and ordered filed. A let-
ter was read from the First Aid and Safety Squad
of the Belmar Fire Department in which it was
requested that the doctors cooperate with the
squad by giving them a special memorandum,
or order, to prevent delay at hospitals. On motion
of O. R. Holters, seconded by H. B. Slocum, the
matter was referred to the Committee on Public
Relations.
J. C. Clayton reported, as a member of the
State Society Welfare Committee, the opposition
to passing the so-called Jones-Cooper Bill. On
motion of Dr. Clayton, seconded by W. G. Herr-
man, it was carried that the Secretary write to
Congressman H. G. Hoffmen and advise him of
our opposition to this bill, which is a revival of
the old Sheppard-Towner law.
On motion of Dr. Clayton, seconded by Dr.
Warner, the Minimum Fee Schedule of the
County Society is to be enclosed to all new mem-
bers at the time of notification of election to
membership. It was also moved and carried that
a Code of Ethics be incorporated in the new Con-
stitution and By-Laws. On motion of Dr. Slocum,
seconded by Dr. Clayton, it was carried that when
the new Constitution and By-Laws are accepted
all present members and all new members be re-
quired to sign same.
Drs. J. Nelson Douglas, of Manasquan, Emer-
son S. Haines, Asbury Park, and Benjamin S.
Levine, Asbury Park, were elected to membership.
The applications of Drs. Morris Woronoff, Frank
Niemtzow, George G. Reynolds and William Mat-
thews were read and referred to the Board of
Censors.
Dr. George N. J. Sommer, President of the State
Medical Society, spoke on the revival of the
Woman’s Auxiliary.
The paper of the evening was given by Dr.
David Warren Kremer, on “Circulatory Disturb-
ances of the Extremities in Diabetes”.
A buffet lunch was served.
PASSAIC COUNTY
Wayne W. Hall, M.D., Reporter
The regular meeting of the Passaic County
Medical Society was held at the Health Center,
Paterson, February 12. The minutes of the Jan-
uary meeting were read and approved.
The scientific program consisted of a paper on
the “Treatment of Bright’s Disease”, by Dr. Rolfe
Floyd, Attending Physician, Roosevelt Hospital,
New York. This paper stimulated considerable
discussion and the speaker was requested to send
it to the Journal for publication.
The following doctors were elected to member-
ship: Fritz Plinke, 99 Gregory Avenue, Passaic;
Nicholas Palma, Broadway, Paterson; George W.
Surgent, Clifton, N. J., by transfer from the Al-
bermarle County, Virginia, Medical Society.
The following applications for membership were
received: James Marshall Allen, 67 Main Avenue,
Passaic; Albert S. Irving, Radburn; and M. Joel-
son, 122 Paterson Street, Paterson.
Dr. Carlisle announced the schedule of lectures
to be given each Friday at 8:30 p. m., beginning
in April. There will be 4 lectures devoted to gas-
trointestinal surgery and 4 to medical gastro-
enterology. The fee for this course is $30.
SAT/EM COUNTY
William H. James, M.D., Reporter
The Salem County Medical Society met at the
Memorial Hospital, Wednesday, February 11, at
2 p. m. The meeting was not very largely attend-
ed owing to the epidemic of La Grippe and var-
ious other winter diseases.
President Frank Perry, of Woodstown, called
the meeting to order and we had as our guest
speaker Dr. Frederick J. Kalteyer, Associate Pro-
fessor of Medicine at Jefferson Medical College.
Dr. Kalteyer gave a most interesting lecture on
Constitution and Colitis, illustrated by moving
pictures from the Mayo Clinics.
Among other things, Dr. Kalteyer said that
frequent purgation that produces watery stools is
very dangerous. The essential remedies were
rest and diet. Chronic constipation in time will
produce anemia, skin eruptions and dizziness.
The paper was freely discussed and a great deal
of practical knowledge was obtained.
At the close of the meeting the usual dinner
was enjoyed at the Johnson Hotel.
SOMERSET COUNTY
J. L. Young, M.D., Reporter
The Somerset County Medical Society held its
meeting in the Nurses’ Home of the Somerset
Hospital on February 12, Dr. E. G. Brittain pre-
siding.
The following applications for membership in
the Society were read: Drs. Louis D. Hind, S. H.
Husted, Alfred Sferra, Berner Wallock, and
George E. Barbour. These applicants were
voted upon and made regular members.
Letter read from Dr. Carrins asking to be al-
lowed to withdraw his application since he was
not going to locate in New Jersey; withdrawal
was granted.
Communication from Dr. Lathan asking that
the society investigate telephone company’s list-
ing names in telephone directory as doctors. Mo-
286
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
March, 1931
tion made and carried that secretary investigate
this matter and answer as he saw fit.
The president appointed Drs. Ely, Halstead, and
Lawton as members of Good and Welfare Com-
mittee.
There was an open discussion as to the rights
of insurance companies to regulate medical fees
in compensation cases; following this there was
appointed a committee of 3 to formulate a reso-
lution condemning this practice of insurance com-
panies.
SUSSEX COUNTY
P. H. Morrison, M.D., Reporter
The bimonthly meeting of the Sussex County
Medical Society was held January 29 at the home
of Dr. F. p. Wilbur, in Franklin. There was a
large attendance of county physicians and a most
enjoyable evening was shared by all present.
The guest speaker of the evening was Dr.
Spencer T. Snedecor, of Hackensack, who spoke
on “Medical Economics”.
Dr. J. Bennett Morrison, Secretary of the New
Jersey State Medical Society, and Dr. Henry O.
Reik, Editor of the New Jersey State Medical
Society Journal, were also present and made brief
addresses.
Following the official session, the doctors and
their wives enjoyed a buffet supper which was
served by Mrs. Wilbur and Mrs. Drake, acting as
hostesses.
Obituaries
BLAKE, Duncan Williamson, of 212 Third st.,
Gloucester City, New Jersey, who was born of
Amos R. and Elizabeth F. Blake, March 7, 1844,
in Philadelphia, died at the age of 87.
He was married and had five children.
Dr. Blake attended Terall’s Academy, Chester
County, Pennsylvania, and graduated from Jeffer-
son Medical College. He reported for military duty
during the civil war and was present at the sur-
render of General Lee to General Grant at Appo-
matox Court House. He was also Pension Exam-
ining Surgeon, at Camden; member of Chosen
Freeholders of Camden County; and member of
Board of Education and School Physician, Glou-
cester City. He was especially interested in edu-
cation.
Resolutions on the death of Dr. Duncan W.
Blake, Sr., adopted at a special meeting of the
Camden County Medical Society:
Whereas it has pleased Almighty Providence to
remove by death from our professional circle, Dr.
Duncan W. Blake, Sr., an honorary member of this
Society;
Be it Resolved, That we hereby give expression
of our sorrow at his departure; and to do honor to
his memory.
Dr. Blake was active in the professional and
also the political affairs of this county; and he
truly represented that fast disappearing type—
“The Old Family Doctor.”
As a general practitioner of medicine, he was
recognized by his confreres as a very able mem-
ber of the profession and he was beloved by a
very large clientele, whom he served so faithfully
for a long period of years.
H. F. PALM, M.D.
J. F. LEAVITT, M.D.
W. H. PRATT, M.D.
KITCHEN J. M. W., of East Orange, died
February 3, at the age of 84.
Born in Newark, Dr. Kitchen was educated at
Newark Academy and Pennsylvania State College,
where he received the degree of M. S. Choosing
a medical career, he entered the College of Physi-
cians and Surgeons of Columbia University, gradu-
ating as an M.D. in 1882. He practiced in New
York 18 years before removing to East Orange.
Dr. Kitchen was widely known some years ago
as a crusader for pure milk and inventor of de-
vices for saving fuel and heat. The pride of Dr.
Kitchen’s long list of inventions was a sanitary
milk container devised after much experimenta-
tion on a farm he had in New Hampshire. He
also conducted experiments there on cattle breed-
ing and crop production.
Going to East Orange at the turn of the cen-
tury after practicing medicine in New York, Dr.
Kitchen took special interest in the pure milk
problem and became a leader in raising the stan-
dard of milk, especially that for infant feeding,
lie was keenly interested in civic affairs and wrote
extensively about them. He founded a dairy com-
pany in East Orange that produced milk under
what were called the Robinswood Farm methods.
His container was designed to protect milk in
bottles from infection.
His other devices pertained to production of
heat, light and power. Dr. Kitchen once was a
familiar figure at the Patent Office in Washington.
While there he made a study of the activities in
the Deparment of Agriculture and assisted officials
in investigating milk and butter infections. The
physician had a large collection of his inventions
on his estate, which was one of the largest in East
Orange. He made a hobby of flower cultivation and
had large greenhouses on his property, which ran
from Prospect Street to the west side of the en-
closure at Ashland Stadium.
DcGROFFT, Eugene E., died January 5, 1931,
at his home in Woodstown, aged 80 years.
Dr. DeGrofft was born in Smyrna, Delaware,
October 3, 1850. His parents moved to Auburn,
N. J., in 1859, where he attended public school
until 1863, when he enlisted as a drummer boy in
one of the Maryland regiments. He was a school
teacher from 1867 to 1869, and then studied pharm-
acy in the drug store of Dr. Johnson, at Penns-
grove. He was graduated from the Jefferson Medi-
cal College in 1875. He practiced medicine at
Mullica Hill from 1S75 until 1892, and then moved
to Camden, where he practiced until 1900, and to
Woodstown, where he practiced until recently.
The death of Dr. DeGrofft removes from us a
man of high professional standards — esteemed
professionally and beloved socially. He was
spared the disability which overtakes many men
before they reach the age which he attained, for
he was able to pursue his work until a few weeks
before his death.
Dr. DeGrofft was an actice member of the
Salem County Medical Society and had contribut-
ed several valuable papers to the society.
He was a member of the Medical Society of
New Jersey, the American Medical Association and
the Philadelphia Club, and served as Physician to
the County Home near Woodstown.
He leaves a widow and 2 sons by a former mar-
riage. Dr. Vernon C. DeGrofft, of Swedesboro, and
William C. DeGrofft, cashier of the Woodstown
National Bank and Trust Company.
287
Journal of The Medical Society of New Jersey
Under the Direction
of the Committee on Publication
Vol. XXVIII., No. 4 ORANGE, N. J., APRIL, 1931
Subscription, $3.00 per Year
Single Copies. 30 Cents
A DOCTOR’S CONFESSION OF FAITH—
I SPEAK OF THE CHILDREN OF
HIPPOCRATES, OF THE CULT
OF AESCULAPIUS*
Wells P. Eagleton, M.D.,
Newark, N. J.
One day in the middle of the last century,
a sensitive young Englishman, a recent gradu-
ate, after a few months in English mercantile
life, depressed by its narrowness, suddenly de-
termined to visit America. Landing on a
beautiful Sunday morning he walked up
Broadway. Suddenly he stopped and joy-
ously exclaimed to himself : “This is the coun-
try for me ; there are no poor.” Later, to his
only child he often said: “Wells, don’t make
the mistake that I did ; don’t enter business ;
don’t be a white collar drudge. Have your
craft in your hands or your profession in
your head ; be a painter ; be a lawyer ; be a
parson ; but best of all, be a doctor for you
will acquire medical traditions — and if you are
true to them, its practice will satisfy the crav-
ings of your soul. For the thought of all
trade — be he clerk, or financier — is profit for
self ; while the ethic of the true physician is
achievement that chiefly benefits another, even
all humanity. The merchant at most can but
make a fortune, which is ephemeral, but the
physician can make a name which may en-
dure.”
And in time that Englishman and his wife
*(An Address at the 33rd Annual Banquet of the
Washington Medical and Surgical Society, May-
flower Hotel, Washington, D. C., May 5, 1930.)
were on-lookers as that boy with his class,
stood, while the Oath of Hippocrates was
read to them in Greek; not one word of which
did that boy understand, although the English
curriculum had compelled the father to be a
“Grecian”.
One day the god Apollo, son of Zeus, the
mighty ruler of the world — Apollo, the per-
fection of manly form — Apollo, who possess-
ed the intelligence of Zeus, his father, and the
agility of Mercury, his brother, had a son,
Aesculapius, who turned his thought to the
curing of the bodies of men. “For”, said
Aesculapius : “Does not my grandsire Zeus
care for the intelligence, and my father Apollo,
look to their comeliness and strength, and so,
I, Aesculapius, will cure their ills.” And the
power of Aesculapius so increased that at last
he raised the dead; which did not meet with
the approval of Zeus, because Zeus being a
conservative, thought “if this offspring of mine
can make people live forever, some day some
one may think he can rule the world as well as
I” ; and Zeus killed Aesculapius with a thunder-
bolt. And then, perhaps in contrition, he placed
Aesculapius among the constellations; and if
we will but fix our minds on the heavens, we
can catch gleams from the constellation of
Aesculapius, our forbear.
For while Aesculapius lived, he established
a fraternity, the Cult of Aesculapius, in which
all were brothers who devoted their lives to
healing. And not only were the Aesculapians
healers, they were priests — for it was a divine
calling that has been handed from sire to son,
to grandson, to this day ; and with their mighty
ancestor a constellation among the stars, the
JOURNAL OF THE MEDICAL SOCIETY OF xVEW JERSEY
April, 1»31
288
Cult of Aesculapius grew strong and power
fill.
The original practice of the cult was
largely a temple worship, it had to do with
dreams and incantations and suggestions,
much after the present mode of psycho-an-
alysis. Its insignia was the serpent, the sym-
bol of wisdom. But the Greeks were a wise
people ; they soon learned not to take the
Aesculapians as seriously as we moderns
have1. Incantations gradually gave place to
the worship of nature; for the Greeks looked
life fully in the face — and the beauty of na-
ture, the beauty of the human form, became
their religion2.
Soon the priests, doubtless perceiving that
they were being found out, employed physi-
cians to assist them with their cures and to
do their surgery. Apd one day down in the
Pelopoponesins, amid the pine trees of Epi-
dauras, surrounded by glorious mountains yet
sea washed, Mrs. Eagleton and I scrambled
over what was once reputed to be the most
beautiful temple in all Greece, the serpentine
Temple of Aesculapius; and over that temple
was written : “Only pure souls can enter here.”
And there we saw instruments, curettes and
forceps, of which today’s are but imitations.
These temple physicians understood many
ihings that we think modern : they understood
the necessity of diet, and that nature is the
real curative agent in diseases ; they recog-
nized the critical days in pneumonia ; they
practiced cardiac ascultation3, I think, for a
memorial tablet depicts the Aesculapian. seat-
ed, with his head pressed against the left side
of the sufferer’s chest, apparently listening to
his heart, while an attendant stands, his left
hand on the patient’s pulse with his right arm
outstretched apparently keeping time with its
beat.
So true were these doctors to the ethos of
a profession — a calling — that one day Xerxes
coming as a conqueror (and like all conquer-
ors, to murder and to steal), said of the
Aesculapians: “What manner of men are
these, that contend with one another, not for
money, but for honor?”
And one day Hippocrates4, of the Cult of
Aesculapius, took the real religious ethic, the
ideal, that was in the cult, and adapted it to
the workings ot life; and thus for all time
established a union between the transcendental
and the earthly. This he formulated into an
oath — The Hippocratic Oath :
“I swear by Apollo the physician, and Aes-
culapius, and Health, and all the gods and
goddesses, that, according to my ability and
judgment, I will keep this Oath. To reckon
him who taught me this Art, equally dear to
me as my parents, to share my substance with
him, and to relieve his necessities if required;
to look upon his offspring in the same foot-
ing as my own brothers, and to teach them
this Art, without fee or stipulation. I will im-
part a knowledge of the Art to my own sons
and to those of my teachers, and to the dis-
ciples bound by the oath according to the
law of medicine, but to none others. With pur-
ity and with holiness I will pass my life and
practice my Art5.”
And one day all the extant works of Hip-
pocrates were collected6, but no one knows
which of these were written by the Father of
Medicine7 s. For medicine did not originate in
Greece, but was brought from Egypt, the
fount of civilization. Many days before
Greece, the Egyptians employed special physi-
cians for different parts of the body ; which
makes our present day specialists look rather
old-fashioned. Among them were many
skilled ophthalmologists and dentists, although
I had thought that the art of dentistry or-
iginated in America5.
But the medical profession even then had
notoriety hunters — “up to daters” — among
them; for a papyrus of 1600 B. C. entitled
“How to change an old man into a young man
of twenty”10, is manifestly the work of a
specialist given to exaggeration. Its author
can justly claim to be the father of medical
publicity. I have no doubt that in his day
he was a leader of the medical profession,
had a large practice and died very rich ; but
that, in reality, he was little different from
the self-exploiting specialists and surgeons of
today, that is, possessed of a good technical
knowledge although lacking in real ethical
sincerity, as is shown by the fact that the
papyrus contains the statement that paralysis
on one side of the body is caused by an affec-
tion of the opposite cerebral hemisphere; a
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
289
physiologic truth that was lost for 3000
years ; its anatomic demonstration being fur-
nished by Gall11 only a little over 100 years
ago.
And one day, as we gazed at the Step Pyra-
mid, I was thrilled to learn that its architect,
Imhotep12, was a physician 2900 years before
Christ. When Imhotep died, so great was
his reputation, they made him a god and
placed him among the stars. So, in the whirli-
gig of time, the title of Father of Medicine
has passed from Hippocrates to Imhotep, but
the Hippocratic Oath still lives.
The Egyptians believed that after death
man’s soul is weighed against a feather, the
symbol of truth and justice — a quill — so light
and ephemeral, and still so powerful and en-
during. But the philosophy of Egyptian life
taught what is to be, not what is, and this led
to dogma; and formalism gradually froze the
mind of man; and medicine passed from
Egypt. For medicine is of life, and life lives
and expands in myriads of forms ; and so
long as the mind of man looks frankly at life,
medicine grows. Medicine, like life, is catho-
lic; it is not sectarian.
All countries have made great contributions
•to medicine, but only at such times as man’s
thought was free; for all oppressions stop
thought, and whenever a restraining hand is
placed on the mind of man, be it the hand of
King, Priest or rigid formula, creative medi-
cine, the understanding of life, sickens and
fades. For despotism, priestcraft, rigid form-
ulas, creeds — all that would control the mind
of man — all disguise life, stop an understand-
ing of life. Creeds are but rules of life as
it was; of forms that have been or that have
become ; but life is not confined by rules ; life,
as it grows, as it expands, as it evolves, such
life creates the rules for life that Is Becoming.
“What is important in life is life and not a
result of life”, said Goethe.
Greece, in the height of her thought, sent
many out to colonize and some of the great-
est pages of Grecian history were written in
the colonies. Sicily, even today, furnishes a
most fascinating picture of Grecian culture,
because its great monuments are still standing ;
they are not buried ; the conqueror, that wor-
shipped marauder, has not passed over the
land and swept all beauty away. In Sicily, is
the volcanic mountain, Etna. Its smoking
snow-capped summit, 10,000 feet above a
tropical land, is one of the most entrancing
sights in the world. At its foot, 450 years
before Christ, lived Empedocles. He was a
physician who did such wondrous things that
at last he came to regard himself as a god,
at least he made little effort to discredit the
assertion. But when we think of what he
accomplished it is small wonder. First, he
drained marshes to stop the miasma which in-
fested the city13. And when we consider that
it is only in our day that our own land has
thus been released from malaria, and that
during 2300 years, his knowledge was neg-
lected, it is not for us to question. In an age
in which the gods controlled all the acts of
man and of nature, in a land continuously
stricken by fevers, to observe that an intermit-
tent type of fever was endemic among those
who lived near stagnant water ; to conceive
that removal of the water would eliminate the
disease ; to dream such a dream, and then to
demonstrate that the dream was true, would
try the mental equilibrium of a god.
Empedocles was not only a physician, he
was a statesman, an inventor, a philosopher
and a poet14. All his works were in verse, and,
like all the great, he was a dreamer : “For
each age is a dream that is dying or one that
is coming to birth”15. He dreamed and taught
the natural selection of species and the sex
of plants ; he recognized the weight of the
air, understood the position of the sun in re-
lation to the earth and the planets; and while
he was working miracles of healing, formu-
lating thoughts only fulfilled by Darwin and
Newton, he wrote a Constitution for his city
which established civil equality. No one knows
how Empedocles died, but there is a legend
that he threw himself into the crater of Etna
to lead men to believe that he had been taken
up by the gods ; but the mountain refused to
be a partner to the sham and expelled one of
his sandals. And when I think of Sicily, the
island of Penelope, nymph of the flowers, my
vision is of the white summit of Etna, and
of the aspiring Empedocles, the creative
physician, standing there, looking at the
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
stars, weary after a life of labor for his fel-
low man, still questioning:
“And you, ye stars.
Are you, too, what I fear to become?
Yrou too, once lived;
But now, ye kindle
Your lonely, cold-shining lights,
Unwilling lingerers
******
Weary like us, though not
Weary with our weariness”i6.
Rome came and absorbed Greece with all
her learning ; and Alexandria became the
medical center of the world. And then Celsus
tried to systematize medicine17 ; and Galen
epitomized the medical art of the classical
world18.
Galen, being a man as well as a physician,
was greatly interested in Cleopatra; and from
him we learn that Cleopatra had written 2
books, one on “cosmetics” and the other on
“diseases of women”19 (Whether there was
any relation between them Galen does not
state). Galen believed that Cleopatra had
special recipes for curling and dyeing the
hair29; so, perhaps the “permanent wave” is
not such a modern affectation after all.
In the Second Century something happened
to the mind of man ; again, it became fixed,
held as in a mold ; the mighty spirit of man,
his god-like gift, passed under theocratic dom-
ination. God, the spirit, the truth, life,
could not be looked in the face ; the world
groveled, and with it medicine.
In the thousands of days from Galen to Vesa-
lius, creative medicine slumbered, but to the
credit of the heart of man the tradition of un-
remunerated service was not lost ; for in By-
zantine times a common vow was “By the
Unmercenary Ones” — referring to St. Cos-
mos and St. Dameon, physicians, who visited
the sick without fee. .
Thomas Aquinas, the most learned of all
the theologians, but with a medical mind filled
with faith in the power of the spirit over body,
entered the presence of Innocence the Fourth
while His Holiness was counting the church
money. The Pope, to excuse the accumula-
tion of which Aquinas disapproved, said :
“Father, the Church can no longer say, ‘silver
and gold have I none’,” to which Aquinas re-
plied haughtily — “Neither can the church now
say to the lame, ‘Rise up and walk’ ”.
Then St. Francis came; came in a day full
of hatred; full of dogma; and taught that love
of humanity, love of all life, was the thing;
that loving was living. And one day we stood
on the parapet where St. Francis walke'd and
worked, on the hilltop of Assisi overlooking
the pastures and vineyards of Umbria canopied
by Italian skies, supreme blend of 'beauty and
peace ; and here we could understand how such
surroundings, and on such a highly sensitive
body, could cause the imprint of the Cross
being placed upon him21 ; for environment and
disease both play a role in man’s spiritual
growth22.
The best explanation for the East Indian’s
pessimism is the universal prevalence of
chronic malaria among them. I know that
there are moments in the lives of all thought-
ful and sincere men in which stimulating sur-
roundings force them to see that the great
spiritual power within man actually can talk
with God, as Moses did on Sinai. For life and
my experience persuade me that, no man can
increase his height by an inch, his frame is
given him by his forbears ; no man can en-
large his intellect, he inherits his mind; but
each man’s spiritual possibilities are limitless,
and depend on himself alone; God lends him
His hand, but he rises by his own exertions.
Paracelsus23, the father of modern internal
medicine, then came. Up to his day alchemists
had chiefly tried to convert other metals into
gold ; but it took Paracelsus, the physician, to
show them that they were wasting their time ;
that the object of chemistry was not to create
gold that warps man’s soul but to make medi-
cines to cure man’s body.
Paracelsus .traveled all over the world con-
sorting with barbers, artists, physicians, sooth-
sayers and conjurors, listening to their ex-
periences and traditions, observing life, and
thus he became a great physician, one of the
greatest physicians of all time ; and then, his
greatness affected him and he became a bom-
bast. But his great crime in the eyes of the
medical profession was in burning the Canon
of Avicenna, its medical Bible, and in pub-
licly advertising and delivering his lectures in
the vernacular24 ; the so-called education of
the public (and the exploitation of themselves)
by leaders of the medical profession through
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
291
“radio talks” had not yet come into vogue, and
so he was denounced as a charlatan. But no
matter what the middle ages thought of him,
no matter how he has been defamed, he revo-
lutionized internal medicine, for Paracelsus did
for medicine what Luther did for theology ; he
freed the mind of men from the shackles of
tradition. From the day of Paracelsus, cre-
ative medicine again lived and if we consider
its course we will perceive that the traditions,
the beliefs, the ideals of a people have dic-
tated their contributions to medical progress.
Italy, the fount of esthetic thought, brought
forth Leonardo de Vinci25, and one day while
looking at his St. Jerome we were pleased to
recall that Leonardo was not only a great
painter, but also a great physiologist, and,
above all, he was a great dreamer, for like
all students of life, be they painters, philoso-
phers, physiologists, physicians — if they are
truly great — they are poets, they are idealists,
they are dreamers ; they all sing :
“But we, with our dreaming and singing,
Ceaseless and sorrowless we!
The glory about us clinging
To the glorious futures we see;
Our souls witn high music ringing;
O men! it must ever be,
, That we dwell in our dreaming and singing
A little apart from ye”26.
Leonardo de Vinci lived a court life, but
while working and dreaming he observed life;
and so he discovered the inverted image of
the retina ; he discovered the effect of light
on the pupil ; most remarkable of all, he un-
derstood and described the involuntary move-
ments of animals — the function of the sympa-
thetic nervous system27 — a fundamental truth
neglected until Gaskell28 in our day elucidated
it.
In France, the fount of individualism, the
home of pure thought, Vesalius29 came and re-
created anatomy, and Ambrose Pare revo-
lutionized surgery30. Pare followed common
sense, and not tradition ; he put ligatures
around vessels ; he taught that it was possible
to turn the child in order to deliver it ; and
in an early translation of his works is found
his observations on the treatment of brain ab-
scess— how he used tubing to drain the abscess
and caused the remaining pus to be expelled
by instructing the patient to close his nose
and mouth and to blow into his cheeks, thus
increasing the intracranial pressure. And this
latter device described by Pare in 153631, was
only rediscovered and adopted in 1925.
Visiting French hospitals we met Vesalius
and Pare, Dupuytren32 and Meniere33 and
Charcot34 and hosts of other doctors whose
names previously meant simply a disease. For
the French have a very fine custom. When
you “walk the wards of a hospital” you not
only meet the usual financial Memorial Tab-
lets, but you read the names of the men who
have contributed something to medicine, in
the hospital in which the work was done, al-
though the walls of that hospital may have
long since ceased to stand. The French use
their hospitals to commemorate the advancers
of medical thought, so that the doctor as he
labors has an inspiration to say : “Some day
perhaps I may do something worthy and then
the French people will not forget to engrave
my name among the Children of Hippocrates
of the Cult of Aesculapius.”
In time England awakens ; England who
knows how to make a practical application of
scientific truths ; who has the power to com-
mand without oppression, that has made the
Anglo-Saxon the ruling race of the world.
Harvey35 came and physiology was born ; Mal-
pighi36, and pathology, histology and embry-
ology came into being; Sydenham37, the “Eng-
lish Hippocrates”, who taught that the way
to study disease was not by books but at the
bedside of the patient; a great contribution.
And if I read the signs of the time aright we
must return to the methods of Sydenham, we
must examine the patient ; we must look at
him ; we must feel him ; we must listen to
him; we must clinically, diagnose his disease;
and then, and only then, should we read lab-
oratory reports. From the day of Sydenham
the medical profession waxed strong and Cuts
(the father of Dutch poetry) said of the doc-
tors ;
“Hail, hail ingenious folk, success attend your
ways ;
May fortune send you gold, not merely
empty praise.”
Then came the American and the French
Revolutions, fighting for the rights of man ;
and in that day we find physicians, men of
292
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
culture, became men of public affairs because
of the duty that they felt and the patriotism
that was in them ; and we as doctors are proud
that of the 59 signers of the Declaration of
Independence, 6 were physicians38, who left
their homes to make effective that immortal
document and the work accomplished ; 2
quietly returned to their practices30, while 2
became governors40 of their native states and
one its chief justice41.
America, the mother of technical efficiency,
added her quota, largely in the perfection of
technical details, and McDowell42 and Marion
Sims43 came and passed.
Morton44 and Simpson45 annihilated pain.
Pasteur46 and Lister47 conquered suppuration,
and modern aseptic surgery was born.
One day we found ourselves in the surgical
amphitheater of Sir Victor Horsley43. He
was a great big genial man who really felt
honored that we had come to see his work.
And today I think of his lonely grave in far
off Mesopotamia, and how he, one of the most
distinguished of surgeons, at 59 years of age
insisted on going into unlivable Mesopotamia
while his country was at war because he
thought he was needed; and of his last words
to his wife — -“Don't worry about me, I do not
matter. I can’t live forever. It is the young
that matter”49. And I feel proud that I belong
to his profession.
In America, Halsted50 came ; catne in a day
when surgery was crude ; when “do it quick
and get through with it, don’t mind the blood,
you can’t operate without losing blood”, was
the general surgical doctrine. But Halsted, in
his quiet way, said: “Rough handling of tis-
sue is not physiologic, it matters not whether
the trauma be from an accident or an opera-
tion. The patient suffers chiefly from loss of
blood and from suppression of function. The
surgeon should handle all tissues delicately,
patiently, bloodlessly.” Out of these physio-
logic principles has come the surgery of the
central nervous system, the greatest contri-
bution that American surgery has made in our
day.
Today, as one travels, one is impressed by
the universality of high grade medical prac-
tice throughout the world. We landed on an
island in the southern Pacific Ocean and found
2 doctors with their wives and a few native
nurses, in a hospital made of bamboo, super-
vising medical care of the inhabitants of 14
islands, the furthermost 700 miles away, and
doing as good surgery as is done anywhere in
the world; doing everything from a cataract
extraction to an appendectomy.
We found ourselves in India, India the
home of metaphysical thought, and in a labora-
tory manned by Hindus we saw that sensitive
plants must have a type of nervous mechanism
because plants apparently have cycling “per-
iods of sleep” during which their sensibility is
diminished ; that certain plants apparently
“feel” as they react to injury, and that these
reactions are lessened by “putting them under
an anesthetic”51. All this puts a new construc-
tion on life. It suggests that there is no break of
continuity in the evolution of the nervous
system from the plant to the animal, although
no nerve fibers have been anatomically demon-
strated. While in India the Anglo-Indian
Medical Service took us by the hand and joy-
ously showed us their work, for it is in the
by-ways of the world that the fraternal feel-
ing of the Cult of Aesculapius is most mani-
fest.
We peeped in on Australia, a country that
looks toward America as at a big brother who
has “made good”. And here one day a young
anatomist52 said “the stiffness, the spasticity,
of the legs of the poor fellows who were shot
in the head during the war — the spasticity that
prevents them from walking — is due to an
over-action of involuntary nerves” ; and an-
other new page in surgery of the sympathetic
nervous system was written.
We reached sunny Spain. And we could
understand how, under that incessant glow,
the histopathology of the nervous tissue was
elucidated. For the Spanish people live among
bright pigments ; they think in colors ; they
play with them ; as Goya did. It was through
the appreciation of color by artist scientists
that the anatomic complexities of nervous tis-
sues were unraveled; and this in a laboratory
on the second floor of a house in the poorest
of neighborhoods.53 Creative medicine is a
strange nymph. She comes to her devotees
at odd moments and in unexpected places ; to
Koch54 in the midst of a country practice; to
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
293
Pasteur in the fields ; to Lister in the operat-
ing room ; to the Curies55 in a barn ; but sur-
round her with marble walls and large awards
and she eludes them all. Details are perfected
in laboratories but principles are born in lofts.
Next, Russia, whose philosophy of life is
that there is no God ; that man is God ; that
the living of this life to its full — and that for
all — is the important thing. Russia, that says
only those that work ; work with their hands
or with their heads— for all — shall reap the
harvest. For the Soviet Government says —
you work or you starve.
From the simple fact that the ringing of
the dinner bell will cause the saliva to flow
from a dog’s mouth, Russian thought has
demonstrated that involuntary reflexes de-
pend upon conditions ; that many of the ways
of animals that we have regarded as instincts,
are acquired; that man himself largely cre-
ates his involuntary reflexes as he creates his
spiritual nature56; a profound contribution to
an appreciation of creative life.
What does it all mean? That we as doctors
are the inheritors of a great tradition. That
by our training ; by our insight into life which
that training should bring ; by the spirit that
its traditions should develop ; it is possible for
us to become (no matter in how small a way)
members of a great band. In our own city,
did not Coit57 say babies should have clean, un-
altered milk? And from his years of unremun-
erative toil, the young of all the world are
healthier, and only the Milk Trust richer. He
was true to the traditions of the Cult of
Aesculapius. He gave something big — and it
was commercially valuable — without thought
of recompense.
It is that band that today, as through all
the ages, by infinite labor and joyous self-
sacrifice, is revealing life to man and man to
himself. If the doctor, when he starts life,
but sees the Spirit of the Cult of Aesculapius,
its precepts and traditions will mold him and
he will become a true child of Hippocrates, for
while inheritance is the greatest factor in
man’s physical and intellectual being, it is his
environment and himself that construct his
character. I have never met a lawyer who is
an idealist ; yet he may be an optimist. He
deals with the laws made by man. I am sorry
for the doctor who is not an idealist, for I
think he is missing the greatest thing that
his training and his experience should teach.
Every day, all day, in his practice he may see
the eternal if he but will.
And does it pay? When I think of how dis-
ease has been steadily exterminated, each epi-
demic promptly controlled and life prolonged
for the good and happiness of all — for this is
the aim of the medical profession — when I see
our judiciary so corrupted, and hampered, our
laws so distorted and perverted that govern-
ment almost seems helpless to protect itself — -
then I feel that those who follow the ideal
reap the rewards. How are we going to reach
it and to hold it? There is a beautiful story
about Clemenceau58 — and Clemenceau was a
doctor. Somebody said : “How do you keep
at it, overthrowing government after govern-
ment, always do you fight for what you believe
is for the Republic?” And Clemenceau replied:
“When I falter, I think of my father. He,
like myself, was a doctor. He believed in a
Republic even when the second Empire came
and was mighty. And one day, Napoleon the
little, sent his soldiers and took him, chained
between 2 criminals, simply because he could
not see that ideal sacrificed for which his
countrymen had fought and died. And when
I would falter, I think of my father and I
become he”59.
A doctor, McCrae, who died in the line of
duty in Flanders Fields60, wrote :
“In Flanders fields the poppies blow
Between the crosses, row on row
* if * * * * sje
To you from falling hands, we throw
The torch. Be yours to hold it high!
If ye break faith with us who die,
We shall not sleep, though poppies grow
in Flanders fields.’’
And this same doctor taught his class :
“What I spent, I had;
What I saved, I lost;
What I gave, I have.”
And at the end of the road, we think of Os-
ier’s last saying : “Such good fellowship, all the
way”61. For the longer I live the firmer is my
faith in the idealism of the medical profession
as a whole, the rank and file of the family
physicians of all lands. The vast majority
sing in their hearts “For no one shall work
for money and no one shall work for fame,
294
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
but each for the joy of the working 6\ And
doctors all have been true to their oath : “I
will impart a knowledge of my art— to the
disciples without fee or stipulation.” And the
average doctor can honestly say: “I have prac-
ticed my art in purity and holiness, and its
practice has satisfied the cravings of my soul.”
Bibliography
1. Bick, E. M.: Cult of Askelapios, Annals of
Medical History, Vol. 9, No. 4, page 330, Decem-
ber 1927.
2. Wile, Ira S: The Worship of Asklepios with
special reference to the Tholos and the Theater, An-
nals of Medical History, Vol. 8, No. 4, page 413, De-
cember 192C.
3. Laennec, Rene Theophile Hyacinthe (1781-
1826), author of “De l’Ausculation Mediati, 1818.
4. Hippocrates of Cos, the seventeenth descendant
of the God Aesculapius: born 460 B. C., died be-
tween 365 and 351 B. C.
5. Adams, Francis: The Genuine Works of Hip-
pocrates, published under the auspices of the
Sydenham Society, London, 1849; and New York,
1886.
6. Hieronymus Mercurialis and Louis de Lenios;
Censura Operum Hippocrates, Venet; 1583, 4th mo.
7. Lenios after examination of all works ascribed
to Hippocrates (De Optima Praedicandi ratione
item judicii operum magni Hippocrates liber
urius, Salamanticae, 1585, 12 mo.), admits only 19
works as authentic.
8. Littre, Emile, Oeuvres Completes d'Hippo-
crate, Paris, 1839-53.
9. Seelig, M. G.: Course of Medical History
epitomized. Proceedings of the Staff Meetings of
Mayo Clinic, Vol. 3, No. 6, page 41 (February 8,
1928.)
10. Breasted, Prof. James Henry: The Edwin
Smith Surgical Papyrus of the New York His-
torical Society 1600 B. C., reviewed in New York
Times, March 24, J925.
11. Gall, Francis Joseph (1758-1828); “Anat. et
Physiol, du Systeme Nerveux en General et du
Cerveawen Particular”, Vol 4, Paris, 1808-1820.
12. Breasted, J. H. : Conquest of Civilization,
“Imhotep the wise”, Pyramid Age, page 61, Harpers,
N. Y„ 1926.
13. Hutton, Edward; Cities of Sicily, Girgenti,
page 123, Little and Brown, Boston, 1926.
14. Symonds, J. A.: Studies of the Greek Poets,
Empedocles, page 126, 3rd Edition, Black, London,
1920.
15. O’Shannessy.
16. Arnold, Matthew.
17. Celsus, Aulus Corneleus; date of birth and
death in dispute, probably born in time of Augus-
tus Tiberius and lived until reign of Trojan. He
wrote an encyclopedia entitled: “De Artilus”, 8
volumes of which were a hand-book to medicine.
It was rediscovered in Fifteenth Century and
printed in Florence in 1478, before the works of
either Galen or Hippocrates. (Taylor, H. O. : Greek
Biology & Medicine, page 92, Harrap, London,
1922.)
18. Galinus, Claudius, born about 131 A. D.,
date of death unknown; physician to Marcus Au-
relius; author of S2 authentic medical treatises
and 18 of doubtful authenticity, as well as 30 to
40 manuscripts. (Anthon, Classical Dictionary,
page 529, Harpers 1873.)
19. Neubruger, M., History of Medicine, trans-
lated by Playfair, London, 1910.
20 Walsh, Jos., Galen’s Studies at the Alexan-
drian School, Annals of Medical History, Vol. 9,
No. 2, June 1927, page 143.
21. Rrumbraar, E. B., The Stigmata of St.
Francis of Assisi — Annals of Medical History, Vol.
9, No. 2, June 1927, page 111.
22. Moorman, J. : Tuberculosis and Genius as
Manifested in St. Francis of Assisi, Annals of
Medical History, Vol. 2, page 556, September 1930.
23. Paracelsus, 1493-1541.
24. Todd, T. W., The Medieval Physician, An-
nals of Medical History, November 1929, page 628.
25. Leonardo de Vinci, 1452-1519.
26. O’Shannessy: Ode.
27. Wilhelmj, C. M., A sketch of the life and
work of Leonardo de Vinci : Proceedings of Mayo
Clinic, Vol. 3, November 18, May 2, 1928.
28. Gaskell, W. H., Series of papers, 1888-1896.
29. Vesalius, Andreas (1514-1564), author of De
Humane Corporis Fabrica. Printed at Basle by
John Oporinus in 1543. It is believed that either
Titian or Titian’s brother or son, Horatio, made
the drawings of the dissections. The work was
preceded by the publication of Tabulae Anatomicae,
in 1538, drawn by John Stephen de Calcan who
painted the famous portrait of Vesalius dissecting
a woman’s body, now in the Royal College of
Physicians in London (Riciiardson, B. W. — Dis-
ciples of Aesculapius, Vol. 1, page 80, Hutchinson,
London, 1900).
30. Pare, Ambrose, 1510-1590, Hugenot barber —
surgeon to Henri II, Francis II, Charles IX and
Henri III; author of 10 books on surgery and sur-
gical anatomy, published in 1568; 5 books of Sur-
gery, 1572 (now extinct); 2 books of Surgery, 1573
(Paget, S. Ambrose Par£ and his Times, page 246,
Pulman, 1897.)
31. “When the Patient is in dressing, if there
comes much matter out of the wound, you shall
wish him, if he can, to lie upon the wound, and
now and then by fits to strive to breathe, stopping
his mouth and nose, that as the brain lifted and
swollen upwards, the matter may be the more
readily cast forth.” (“The Works of Ambrose
Par£. Translated by Th. Johnson, London. Printed
by Mary Clark, and are to be sold by John Clark
at Mercer’s Chappel at the lower end of Cheapside,
M1DCLXXVI1I.” “Page 250, Book X." “Of Green
and Bloudy Wounds of each part.” Chapter XXI
“of the discommodities which happen to the Graffa
Meninx by fractures of the Skull.”)
32. Dupuytren, Guillaume (Baron), 1777-1835.
33. Meniere, Emile Antone, first described aural
vertigo (Gaz. Med. de Paris, 1861.)
34. .Charcot, Jean Martin, 1825-1893.
35. Harvey, William, 1578-1657. Exercitatio de
Motu Cordis et Sanguines, was published in 1628.
There is an oil painting of Harvey, by William
van Bemmel, in the Hunterian Museum, at Glas-
gow, which probably was painted from life.
36. Morgagnus, Joannes Babtisia. 1682-1763.
37. Sydenham, Thomas, 1624-1689.
38. Bartlett, Josiah, M.D., 1727-1795; graduated
from Yale; began practice in 1750 at Kingston and
April, 1931
JOURNAL OF THE MEDICAL SOCIETY GF NEW JERSEY
295
acquired reputation during epidemic of Angina
Mialigna, in 1754, by using Peruvian bark. Had
several appointments from the Royal Governor,
John Wentworth, but deprived of them in 1775
because of his political activities. Appointed to
command regiment of militia 1774. He was the
first who voted for and the first, after the president,
who signed the Declaration of Independence. Ac-
companied Stark to Bennington in 1777. President
of New Hampshire 1790. First Governor 1793.
(American Cyclopedia; Ripley and Dana, Vol. 11,
page 350. Appleton, 1874.)
Hall, Lyman, 1725-1790; graduated from Yale
1747. Studied medicine. Practiced in South Caro-
lina and Georgia from 1752. Influential in inducing
Georgia to join the Confederacy. All his property
confiscated by the British during the revolution.
Governor of Georgia 1783. (Amer. Cyclopedia, Vol.
VIII, page 400, 1874.)
Wolcott, Oliver, 1726-1797. Graduated at Yale in
1747 and studied medicine with his brother Alex-
ander. In 1751 entered politics and from there on
apparently did not practice medicine. Raised troops
and helped defend New York in 1776. Commissioner
of Indian affairs of the Northern Department 1775
and negotiated the treaty of Fort Stanik. In cam-
paign against Burgoyne and in defense of Con-
necticut.
Rush, Benjamin, M.D., 1745-1813, studied at the
College of New Jersey and took his preliminary
degree in arts in 1760. Studied medicine for 6
years with Redman in Philadelphia. Took Doctor’s
degree in medicine in Edinburgh University, 1768.
Spent 2 years in medical studies in London and
Paris. Twitted because of his studious habits, he
wrote “Medicine is my wife; science is my mis-
tress; books are my companions” (Richardson,
Disciples of Aesculapius, Vol. 1, page 64). Physi-
cian General Military Hospital 1777. Established
Philadelphia Dispensary 1786. Helped found Dick-
inson College, in Carlisle, President of the Amer.
Society for the Abolition of Slavery. “The loss of
no individual of this country, excepting that of
Washington or of Franklin, has been lamented
with more universal and pathetic demonstrations
of sorrow.” (Biography of the Signers to the
Declaration of Independence, by John Sanderson,
Vol. IV, page 283, Philadelphia 1823-27.)
Thornton, Matthew, 1714-1803. Educated at
Worcester, Mjass. Studied medicine and com-
menced practice in Londonderry, New Hampshire.
Surgeon to New Hampshire Division of 500 men in
expedition against Louisberg in 1745. Colonel of
Militia at beginning of Revolution. President of
Provincial Convention and Chairman of the Com-
mittee of Public Safety. Elected to Continental
Congress and permitted to sign the Declaration
of Independence in September (?) 1776 (Amer.
Cyclopedia, Vol. XV, page 723.)
Taylor, George, 1716-1781. Received a good edu-
cation in Ireland and came to America as a “re-
demptioner.” (Goodrich’s Lives of the Signers, Phil-
adelphia, 1827.) Was an iron worker and a manu-
facturer of iron and later a practicing physician
in Easton, ■ Pennsylvania. Elected to Continental
Congress July 20, 1776. Signed the Declaration of
Independence, August 2, 1776. (Amer. Cyclopedia
Vol. XV, page 592.) Monument erected to his
memory in Easton in 1847 but place of burial un-
known (from old paper presented to Easton His-
torical Society by W. P. Eagleton.) Letter from
Taylor in Broderhead’s Book of the Signers per-
taining to Fac Simile Letters of the Signers of the
Declaration of Independence, Philadelphia, 1861,
page 37-38, from Freeport, N. J., dated March 3,
1776, offering to enter service as commander of
battalion to guard the sea coast.
“In the printed public Journal of Congress for
1776, Vol. 2, it would appear that the Declaration
of Independence was signed on the fourth of July
by the members whose names are there inserted,
but the fact is not so, for no person signed it on
that day nor for many days after, and among the
names subscribed one was against it and several
were not in Congress on that day, namely, Messrs.
Morris, Rush, Clymer, Smith, Taylor and Ross, of
Pennslyvania, and Mr. Thornton, of New Hamp-
shire, nor were the 6 gentlemen last named at
that time members; the 4 for Pennsylvania were
appointed delegates by the Convention of that state
on the twentieth of July and Mr. Thornton en-
tered Congress for the first time on the fourth of
November following.” (From letter of Kean,
Thomas W„ dated Philadelphia, August 22, 1813.
Broderhead’s (William) Book of the Signers per-
taining to Fac Simile Letters of the Signers of
the Declaration of Independence, 1861, page 68.)
39. Rush and Taylor.
40. Bartlett, Hall.
41. Thornton.
42. McDowell, Dr. Ephraim: Born Nov. 11, 1771
—Died June 20, 1830.
43. Sims, James Marion, 1813-1883, organizer of
the Women’s Hospital, New York and Anglo-
American Ambulance in Franco-German War.
44. Morton, William Thomas Green, 1819-1863,
first administered sulphuric ether in 1846.
45. Simpson, Sir James Young, 1811-1870, intro-
duced chloroform.
46. Pasteur, Louis, 1822-1895, first described
bacteria as cause of disease in discussion of child-
hood fevers.
47. Lister, Lord Joseph, 1827, began antiseptic
treatment of wounds in Glasgow, 1865.
48. Horsley, Victor, 1857-1916.
49. Horsley, Sir Victor, 1857-1916, A Study of
His Life and Work by Stephen Paget, Constable,
London, 1919.
50. Halsted, William S., Biography by McCallum,
W. G., Johns Hopkins Press, Baltimore, 1930.
51. Bose, Sir J. C, Growth and Movements of
Plants, Longmans, 1929.
52. Hunter, John L, 1898-1924.
53. Cajal, S. Ramony, 1852.
54. Koch, Robert, 1843.
55. Curie, Pierre, 1859-1906. Curie, Marie Sklo-
dowska, 1867 (Curie, Marie: “Pierre Curie” trans.
by C. & V. Kellogg, Macmillan Co., 1923).
56. Pavlov, I. P., Conditioned Reflexes; trans.
by Anrep, Oxford Press, 1927. .
57. Coit, Henry, 1854-1917, Originator of Cer-
tified Milk under Medical Commissions.
58. Clemenceau, Georges, 1841-1929.
59. Reilly, J. J. de S., The Drive Behind Clemen-
ceau, The Living Age (September 1, 1929).
60. McCrae, John D., died January 28, 1918,
written during the second battle of Ypres, April,
1915.
61. Osier, Sir William, 1849-1919, Biography by
Cushing, Oxford Press.
62. Kipling.
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
TREATMENT OF ACUTE CORONARY
THROMBOSIS
Albert S. Hyman, M.D., F.A.C.P.,
New York City,
and
Aaron E. Parsonett, M.D., F.A.C.P.,
Newark, New Jersey
The incidence of coronary thrombosis,
while probably no greater today than it has
been in previous generations, because of
widespread publicity and more frequent recog-
nition, appears to be on a decided increase.
Modern methods of intensive propaganda,
both in lay and medical publications, have
done much to focus attention on cardiovascu-
lar disease in general, and coronary disease in
the guise of “acute indigestion” in particular.
A staggering mortality percentage following
even the so-called “mild attacks” of this
malady places it high in the statistical tables
of the principal causes of death. Its grue-
some and deadly selectivity among that group
of our citizenry most useful in the average in-
telligent community is only too well known.
Removed at the zenith of his productive abil-
ity, the usual victim of this disease is to be
found among that middle aged class composed
of physicians, lawyers, clergymen, and busi-
ness executives. Even though death may not
supervene, the amazing transformation that
renders a previously vigorous and energetic
individual into a decrepit and enfeebled old
man only serves to swell the roster of those
struck down by this most serious cardiovas-
cular accident.
1 he symptoms of coronary thrombosis in
its protean syndrome have been developed to
such degrees of diagnostic niceties, by the
many contributions made to medical literature
within the past few years, that the subject
requires but little additional elucidation. In
its frank form, the sufferer from coronary
thrombosis is readily recognized by the clearly
defined series of events which transpire in
rapid succession.
Probably the most conspicuous feature of
the attack is the immediate prostration of the
individual ; how much this initial collapse is
due to the prolonged, excruciating, and un-
abating pain and how much to the abrupt al-
teration in the hemodynamic factors of the
damaged heart muscle may be difficult of true
evaluation. Both these factors unquestionably
l’lay an important role in establishing the
general clinical picture of shock. Dyspnea,
cyanosis, pulmonary edema and other signs of
peripheral circulatory failure add to the grav-
ity of the patient’s condition. Pathologic
changes observed clinically in the marked fall
of systolic pressure, and local manifestations
of the necrosing heart muscle suggested by
temperature, leukocytosis and pericarditis,
later to be followed in many instances by em-
bolic phenomena, serve to complete this vari-
gated symptom complex.
Faced with the problem of treating a pa-
tient in the agonizing throes of acute coronary
occlusion it is essential to be equipped with a
thorough and clear concept of the pathologic
processes so rapidly taking place in the crip-
pled heart. Probably in no other acute con-
dition is such knowledge of greater impor-
tance for the successful combating of an ap-
parently hopeless condition ; in the face of
newly acquired knowledge, proper and prompt
therapeutic steps guided by recognition of the
various phases presented by the disease are
not altogether futile.
From a purely clinical point of view, the
acute coronary thrombosis syndrome may be
divided into 3 readily distinguishable stages :
first, the onset with its immediate alarming
symptoms of pain, shock and prostration ;
second, the intermediate stage extending from
about the third day of the attack to about the
tenth, during which time all signs and symp-
toms of necrosing heart muscle become evi-
dent ; and third, the stage of convalescence
which is exceedingly slow and protracted, not
infrequently lasting many weeks and months.
It must be constantly borne in mind, however,
that death hovers no closer in one stage than
in another and with fatal impartiality selects
its victims in any period. Mortality tables
gleaned from many observers place the prob-
ability of recovery slightly less than 50% ; in
other words, any patient has almost an even
chance of recovery.
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
297
With this in mind, therapeutic measures
will be successful only insofar as the proper
stage of the disease is recognized, for the
treatment in one stage may be decidedly con-
traindicated and, perhaps, even hazardous in
another. For this reason, therefore, any con-
sideration of treatment in this disease must be
based entirely upon the stage in which the
patient is seen.
Stage of Onset
When an important blood carrier to the
heart muscle is suddenly stopped, that segment
of the myocardium nourished by this vessel
and its branches is immediately set into a dis-
turbed chemical balance. The initial stage of
anoxemia rapidly gives way to a series of pro-
foundly altered electrodynamic and hemody-
namic response. If the electrodynamic changes
are so intense that the normal cardiac cycle
can no longer be maintained, death immediately
supervenes. This is especially true when the
impoverished segment lies in the walls of the
ventricular chambers. During the period of
anoxemia the myocardium becomes hyperir-
ritable and in it are born many foci for ectopic
beats; when several foci became simultan-
eously operative, ventricular tachycardia will
develop. Depending upon the number and
distribution of such ectopic points is the prob-
ability of ventricular fibrillation enhanced; the
development of this latter condition is usually
promptly fatal. When, however, the infarcted
area lies in the auricular walls, the pathologic
changes which follow are no wise different
than those developing in the ventricular areas
with the important exception that, whereas
ventricular fibrillation is incompatible with
life, auricular fibrillation is not an uncommon
clinical discovery. When this latter condition
occurs the life-saving phenomenon exhibited
by the conducting tissues in filtering out most
of the stimuli arising in the auricle becomes
effective. An adequate circulation can thus
be maintained without great difficulty.
Sudden death, therefore, when it occurs
during the very onset of the attack, is usually
due to the above phenomena ; no remedies of
any kind can be administered promptly
enough, nor with any hope of success in com-
bating its development. As high as 55% of
such individuals are said to die during the in-
itial stage from this cause; for them nothing
can be done. In other cases, the infarcted
area may not be so large nor lie in such im-
portant portions of the myocardium ; electrody-
namic disturbances, if they occur, may not be
sufficiently disturbing to seriously hamper car-
diac function. At the same time the involved
segment may set the entire heart into a state
of irritability still fraught with no little
danger. Complex neurogenic arcs are appar-
ently quickly established and help to augment
the factors of shock produced by such serious
cardiovascular impairment. A profound drop
in blood pressure levels usually accompanies
the local reaction to the infarcted area. This
life-saving mechanism is dependent upon the
peculiar balance established between the needs
of minimum pressure for an adequate peri-
pheral circulation and the resistant qualities of
the damaged heart wall. Where the pressure
is maintained at high level, rupture of the
weakened musculature may result, while, on
the other hand, a too great fall in systolic
blood pressure may lead to urinary suppres-
sion and peripheral vascular stasis.
With these facts in mind, treatment of the
initial stage of acute coronary occlusion
should be focussed upon amelioration of those
factors leading to the extreme shock and pros-
tration. The element of pain is unquestion-
ably of the greatest importance; the agonizing
and crushing character of this pain tends to
enhance the danger and likelihood of increased
myocardial damage, since agitation of the pa-
tient as he restlessly thrashes from side to
side will quickly complete the picture of ex-
haustion. For this there is only one remedy;
narcosis, no matter how produced, is to be
sought for as expeditiously as possible. While
a wide variety of drugs may prove to be use-
ful for this purpose, morphin is, in the last
analysis, of the greatest help. Dosage of this
drug to be effective, must be large; this is
no place for the timid and halting administra-
tion of the remedy. We have never given less
than ^2 gr. for the initial dose subcutaneously ;
morphin in this instance is practically useless
when given orally. The question is often
asked, how much morphin can be given in such
cases with safety ? The answer seems to be
298
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
that morphin can be given in larger doses in
acute coronary thrombosis than in any other
known disease condition, and the full dosage
is only achieved when the patient is rendered
free from pain. If this result can be obtain-
ed by minimum dosage, no further medication
may be necessary in the satisfactory handling
ot the case; more frequently, however, large
and massive doses are required, running as
high as several grains in the first 24 hours.
We have never seen any untoward results
from such large dosage, but we have seen pa-
tients who have been insufficiently narcotized
because of the timidity of the medical attend-
ant.
From time to time individual cases may be
found where the pain factor is so overwhelm-
ing that nothing short of general anesthesia
is of the slightest value. It has been neces-
sary in 2 of our cases to resort to administra-
tion of ether in order to prevent the pa-
tient from literally tearing himself apart in
frantic attempts to secure respite from the
terrific stenocardia. General anesthesia in
acute coronary occlusion must, however, be
used with the greatest caution, as its contra-
indications far outweigh the rather dubious re-
sults to be expected.
Other drugs of the opium series like codein,
pantopon, papaverin, and tincture of opium
have also been suggested by many authors;
all these drugs may prove to be more or less
efficacious in individual cases but the results
obtained never approach those secured by
morphin itself. Of the hypnotics, luminal,
allonal, dial, and the bromides in one form
or another, have been suggested in those cases
where the pain factor is not especially con-
spicuous. We have found, however, that
even in such cases a small dose of morphin
may prove to be more reliable than any of
these.
Next in importance is control of the symp-
toms of shock; little need be said concerning
this as it differs in no way from shock and
prostration met with in other conditions.
Warm blankets and hot water bags should be
used liberally to combat the vasomotor col-
lapse associated with the cold, clammy sweat-
ing found in this condition. One exception
might be made in treatment of the shock
occurring as a result of a coronary accident,
and that is in regard to the relation of the head
to the rest of the body ; when shock occurs as
a result of accident or after a surgical opera-
tion the patient’s head is usually lowered, the
belief being that an adequate cerebral circula-
tion must be maintained in this way ; in coron-
ary occlusion, however, the head must be kept
elevated and, indeed, if the dyspnea, accom-
panying the attack be marked, the patient will
himself insist on assuming a more or less up-
right position
Ordinarily, no other treatment is required
during the initial stages of the attack ; the
question of stimulation may arise if the peri-
pheral circulation is markedly impaired. Hypo-
dermic administration of adrenalin, strophan-
thin, either alone or in such combinations as
digibaine, digitalis, or caffein sodium ben-
zoate, may be given. Here again, as in the
use of morphin, dosage must be controlled
by the signs of full physiologic effect. In
desperate cases intravenous administration of
these substances may be demanded ; only under
the most unusual circumstances is the intra-
cardiac administration of these substances to
be recommended. If cardiac arrest occurs,
this latter method of treatment may save an
otherwise hopeless individual. It has been our
experience that intravenous medication is pre-
ferable so long as the heart is beating ; when
cardiac standstill occurs, intracardiac medica-
tion must be resorted to.
A word in regard to the use of digitalis
must be made here. Inasmuch as the heart
in acute coronary thrombosis is usually regu-
lar and the action slow, nothing can be hoped
for from this drug, while, on the other hand,
owing to increased irritability of the ventric-
ular musculature, heart block and ventric-
ular fibrillation may result. If circulatory
failure is present at this time, digitalis may be
used, but the indications for its use are rather
infrequent.
Intermediate Stage
Forty-eight hours after onset of the initial
attack finds the patient more or less relieved
from the terrific pain and recovering from the
symptoms of shock and prostration. He will
then be .concerned with gastro-intestinal com-
April, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
299
plaints, chief of which is a peculiar type of
nausea unrelieved even if vomiting occurs. It
is strange that although this symptom is one
of the most conspicuous features of the entire
attack and next to the pain factor is the one
most often recalled by the patient, this type
of nausea has received but scant attention in
literature. Relief of this symptom may cause
the medical attendant no little concern, as the
ordinary measures for combating such com-
plaints are useless. While there seems to be
some question as to the actual origin of this
nausea, whether it be local in the stomach,
reflex from higher centers, or the result of
vascular changes in the mesenteric division of
the arterial tree, there can be no question but
that it presents an almost insurmountable
problem for therapy. Probably no remedy in
our experience has been as efficacious as em-
ployment of the alcohol-sugar combination or-
iginally suggested by Libman ; these mixtures,
the Volstead Act notwithstanding, may be
and frequently are life-saving at this critical
stage of the disease. Of these alcohol-sugar
mixtures the essential liqueurs like creme de
menthe, creme de cacao, benedictine, Coin-
treau and others if available, may promptly
control this most distressing symptom. Given
in 1 oz. doses with cracked ice every hour or
two, our results have been almost uniformly
favorable. The difficulties encountered in se-
curing these remedies have made it necessary
for us to develop synthetic formulas for them.
At the Beth David Hospital, for example,
synthetic creme de menthe and creme de
cacao, fortified with theobromin sodium salicy-
late to prevent diversion into unorthodox chan-
nels, have been used for the past several
years. The official U. S. P. preparations of
elixir aromaticum to which has been added an
equal volume of grain alcohol is perhaps the
most readily obtained synthetic liqueur avail-
able to the general practicing physician.
Gastric lavage cannot be too strongly con-
demned and is mentioned here only to focus at-
tention upon the need for correct diagnosis ; as
indicated previously, the gastro-intestinal
symptomatology of the coronary thrombosis
syndrome may so predominate in the clinical
picture that erroneous conclusions may be
easily drawn and the case treated as an acute
gastro-intestinal upset. Likewise, cathartics
and strong purges must be carefully avoided
and enemas if given should be only of the
blandest type and in restricted volume.
Associated with the nausea may be a pain-
ful type of eructation; patients frequently
plead for relief from gaseous discomfort and
indeed the belching of gas may be followed by
prompt amelioration of all symptoms. To the
usual remedies for this complaint may be
added the cautious administration of carbon-
ated waters.
About this time local manifestations of the
cardiac injury will be making themselves evi-
dent ; there will be a slight rise of tempera-
ture, moderate leukocytosis, and perhaps the
evidences of pericardial involvement. Ordin-
arily the area of pericarditis is not sufficiently
large to give the patient much discomfort but
an ice bag placed over the precordium will do
much to relieve heart consciousness. If the
signs of circulatory failure with pulmonary
edema, engorgement of the liver, ascites and
pitting of the lower extremities supervene,
digitalization should be proceeded with at once.
We wish to take this opportunity of warning
against the massive dosage method so popular
in other cardiac conditions ; the hazards in-
vited by rapid digitalization in coronary
thrombosis greatly enhance the probabilities
of embolism. Digitalis in combination with
caroid or any other proteolytic ferment in
doses up to 8 or 10 gr. a day seem to be the
most satisfactory. Diuretics of the group
like metaphyllin, theobromin calcium salicy-
late, theominal and others are also useful.
Dyspnea and cyanosis may be difficult to
control even when there does not appear to be
marked signs of circulatory failure. With a
slow and regular pulse and with no discov-
erable indications of edema the dyspnea and
cyanosis may still be very great. If difficulties
of breathing approach orthopnea, sedatives
may be required. Within recent times oxygen
therapy has been used with striking results ;
administered either by an oxygen tent or by
the intranasal catheter route, patients appar-
ently obtained prompt relief, so much so, that
they demanded its administration. In ex-
tremely severe cases, pure oxygen has even
been injected intravenously with a favorable
300
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
outcome. Oxygen is, however, a recent addi-
tion to therapy and sufficient data are still not
easily available for true estimation of its ef-
ficacy.
Irregularities of the pulse ordinarily require
no specific medication inasmuch as they are
merely manifestations of the myocardial re-
action to injury sustained by the occluded cor-
onary vessel. Most irregularities are extra-
systolic in origin and may be disregarded ;
when, however, they occur very frequently
and tend to produce paroxysmal tachycardia
they must receive special attention. Quinidin
sulphate has been recommended by Levine for
this latter condition ; we have also used stro-
phanthin with favorable results.
When the myocardial damage has been so
extensive as to cause complete heart block the
complications of this type of arhythmia may
lead to the symptoms found in the Stokes-
Adams syndrome ; periods of unconsciousness
lasting from a few seconds up to several min-
utes may be successfully combated by adren-
alin injected hypodermically, and in extreme
cases by the intracardiac method.
Stage of Convalescence
As the patient approaches the tenth day he
may be considered as having escaped the im-
mediate hazards so inherent in the acute phase
of this disease. The temperature by this time
has probably completely subsided ; the leuko-
cyte count, on the other hand, may still re-
main somewhat increased. Libman has pointed
out that the white blood count offers a far
more accurate index as to the reparative pro-
cess in the myocardium than the temperature
curve ; for this reason he would keep such
patients at rest in bed until the count reaches
a normal figure, regardless of any other nega-
tive symptoms. While this may be a good
general rule to be carried out if possible, many
patients, more especially those of a hyper-
active temperament, may become so restless
under the enforced regime of prolonged bed-
rest that more harm than good will result.
Such individuals may actually develop a sec-
ond attack of coronary occlusion because of
the extreme irritability entailed ; it is a well
established fact that an uneasy state of mind
will often lead to or precipitate a secondary
attack. For this reason, therefore, the medical
attendant must invoke his clinical judgment
and experience in determining just how long
any individual patient should be kept in bed,
remembering always that the best interests of
the patient are those conducive to complete
mental and physical repose. If this can be
secured by bed rest the problem is consider-
ably simplified ; where, on the other hand, the
patient is the type previously described, it may
be necessary to get him out of bed and into a
comfortable chair as soon as this is compatible
with safety.
Medication at this time has probably been
reduced to symptomatic needs in those pa-
tients who have suffered no serious complica-
tions during the first and second stages of the
disease. The question may arise as to how
long coronary dilatation therapy should be
continued? Ordinarily, if the blood pressure
levels are still low but the pain factor gone,
the special indications for this group of reme-
dies are less apparent than in those cases where
the pressure has quickly risen to the former
high levels. When the original signs of cir-
culatory failure have subsided, digitalis should
be discontinued at once, but to be resorted to
from time to time as signs of decompensation
make their appearance. Indeed, prolonged ob-
servation of coronary patients extending over
some years will show an entire gamut of myo-
cardial degenerative changes during which
many local signs of the decompensated heart
will become evident ; pulmonary edema, in
chronic or acute forms, circulatory stasis
phenomena with engorged and tender liver,
general and local edema, all will demand spe-
cific and prompt digitalization. Irregularities
of the pulse and conduction disturbances not
infrequently go hand in hand with the other
symptoms of myocardial failure ; the electro-
cardiograph will be of great assistance in dis-
tinguishing the types of such disturbances. All
of them, in the last analysis, are merely differ-
ent phases of the same degenerative etiologic
background and therapy to be of any value
must point toward the establishment of better
nutrition of the heart muscle. Where this
can be secured by improvement in muscle tone
and general contractility of the myocardium,
digitalis and its allies are to be utilized in full
April, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
301
physiologic dosage; as the fear of emboli in
this stage, in contradistinction to the others, is
remote. More often, however, those remedies
seeking to establish a better coronary circula-
tion are to be preferred ; in our experience,
metaphyllin has rendered the most consistently
good results. Of the more recent remedies,
acecolin, either alone or in combination with
dextrose, administered intravenously may be
of definite prophylactic value. A series of 6
injections given on alternate days has in a
group of 56 cases rendered very laudable re-
sults in that of the entire group only 16 had
subsequent attacks during a period of 18
months of constant observation.
A word in regard to dextrose alone ; in our
experience this has been the one substance of
undisputed value when given intravenously in
the second and third stages of the coronary
attack. In spite of the general widespread
belief that dextrose should be given in very
dilute form, we have found that 50% solutions
are readily tolerated by the patient. Our
usual dosage has been from 10 to 20 c.c. of
this strength repeated every other day. In a
series of nearly 1000 injections at the Beth
David Hospital there has not been a single
untoward result ; very rarely patients com-
plain of a peculiar taste immediately following
injection of the dextrose, and from time to
time others speak of a flushing of the face.
An interesting difficulty in the treatment of
coronary thrombosis is encountered in diabetic
individuals ; Levine has shown that as high as
24% of the patients studied in his series were
known to have had diabetes. This figure
would suggest that this disease is not an un-
common complication in the coronary syn-
drome and when discovered the question of
insulin administration immediately arises.
Friedman was the first to point out that dia-
betic patients are rendered more susceptible
to coronary pain when insulin is given in the
attempt to reduce hyperglycemia; in fact,
severe coronary attacks are often precipitated.
Unless the blood sugar has reached danger-
ously high levels and acidosis is likely, insulin
should not be employed. Dietary measures
including even the older, and now unpopular,
starvation methods should be tried.
This brings us to the question of diet in
general and we wish to point out here that
no hard and fast rules can be laid down in re-
gard to special dietary measures. During the
first stage of the disease the problem is ex-
ceedingly simple, as the patient will himself
refuse all food. Fluids like the citrous fruit
juices, thin gruels and albumin waters and
some of the fermented milks will comprise the
total selection. If the nausea and vomiting
factors are prominent, the dangers of dehy-
dration must not be lost sight of ; a careful
check of the water balance must be one of the
essential nursing procedures. Where there is
a negative balance and the output considerably
diminished, immediate measures must be un-
dertaken to correct this feature. During the
second stage of the malady the choice of diet
is considerably augmented and is comparable
to the average soft diets as used in most hos-
pitals ; the exception being the total exclusion
of ordinary milk. We cannot too strongly in-
terdict the use of milk diets like that of Car-
rel so frequently employed during these stages
of the disease. In our experience, milk taken
by such patients leads to considerable gastric
distress and, if anything, adds to the discom-
forts already present. Unless there is some
definite contraindication, a relatively high
carbohydrate ratio should be maintained; such
substances as honey, molasses, or sugar syrups
can be given liberally.
At approach of the third, or convalescent,
stage a rather liberal selection may be per-
mitted ; with the exception of heavy proteins,
the diet need vary in no wise from that of a
careful normal diet. We have no special ob-
jection to tobacco, tea or coffee, so long as
these are kept within moderation and, indeed,
we feel that in certain instances they may be
especially beneficial. Of great importance to
the patient is the problem of physical activity,
and such questions as “when can I go back
to work”, “how far can I walk”, “can I play
golf or do any gymnastic work”, “can I in-
dulge sexually”, and many others of similar
nature, greet the medical attendant sooner or
later in every case of coronary disease.
The answer to this very complicated phase
of the disease is one which requires the ut-
most caution ; realizing on the one hand that
sudden death may overtake such patients at
302
JOURNAL OF THE MEDICAL SOCIETY OF 1STEW JERSEY
April, 1931
any time, and, on the other, that a certain
amount of exercise is therapeutically indicated,
it may be a question of fine discernment to de-
termine how much or how little the patient
may be permitted to do. Here again, no gen-
eral rule can be made elastic enough to cover
all cases and it will be necessary to take into
consideration not only the patient’s previous
habits but also the extent of damage suffered
during his first or subsequent attacks. Prob-
ably in no other instance in clinical medicine
will good judgment and experience stand the
doctor in better stead in determining the fu-
ture conduct of individuals. Gradually increas-
ing the amount of physical exercise until the
patient’s daily routine has been reestablished
to a point to render his forced seclusion less
irksome, but conducive to safety, is the ideal
goal to be sought.
THE CLINICAL SIGNIFICANCE OF
HIGH AND LOW BLOOD PRESSURE*
R. Burton-Opitz, M.D.,
New York City
I have selected this particular topic because
a study of the large array of papers on blood
pressure published each year proves that their
authors are frequently quite ignorant of the
fundamental laws of pressure. An error re-
peatedly made is to consider blood pressure
as an entity, while in reality it is the result
of the interaction of several factors. Thus, it
is stated in “Classification and Diagnosis of
Heart Disease”, by Bainton, Levy, Munty and
Pardee, that: “Essential hypertension is a dis-
order in which the arterial pressure is per-
manently increased without cause. It is a dis-
turbance in function rather than in structure.
In the early stages of it there may be no
signs other than the increased arterial pres-
sure, while later on there may be an enlarge-
ment of the heart. When other cardiac signs
and symptoms appear, it is probable that ar-
teriosclerosis of the aorta or coronary arteries
has developed. For the purpose of this classi-
*(Read before the Bergen County Medical So-
ciety, September 9, 1930.)
fication the term of hypertension as an etio-
logic diagnosis should be restricted to cases
without demonstrable arteriosclerosis. When
the latter is present, the etiologic diagnosis
should be entered as arteriosclerosis, the
hypertension being then a physiologic diag-
nosis.”
Questionable statements of this and similar
kind appearing in print from time to time do
not render this subject more comprehensive
but tend to dim the issue. The classification
offered by these authors cannot be accepted,
because it is not built upon a solid physiologic
basis. Just as surely as blood pressure is a
product derived from the interaction of a
number of physiologic processes, so may
every increase or decrease in pressure be
traced to one or several of its causative fac-
tors. Keeping this in mind, it will be seen
that such terms as “essential hypertension”
must be used with care. Essential means in-
dispensable and necessary. In a medical sense
it refers to something idiopathic and inde-
pendent of others. Blood pressure is a normal
physiologic function. It is not idiopathic.
Consequently, any labnormal state, such as
hypertension or hypotension, must be the re-
sult of an abnormal interaction of its causa-
tive factors. Hypertension is no more essen-
tial or idiopathic than pneumonia or any other
pathologic condition.
The principal factors responsible for blood
pressure are: (a) the energy of the heart;
(b) quantity of the circulating blood; (c)
elasticity of the vessels; (d) the peripheral
resistance. Each ventricular systole forces
about 60 c.c. blood into the aorta. Assuming
that the other 3 factors remain constant, the
pressure must rise whenever the energy of
the heart is increased and fall whenever it is
decreased. The ventricular output is pro-
portional to the cardiac energy and is based
upon the following secondary factors: the
volume of each discharge, the frequency with
which these discharges are repeated, and the
force with which they are effected. The first
is determined by the capacity of the cardiac
chambers, or their power of filling; the sec-
ond concerns the cardiac output per unit of
time in that the aorta usually receives about
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
COS
4 liters of blood in the course of 1 minute ; the
third pertains to the force of ejection.
The total quantity of the blood is calculated
at 1/20 to 1/13 — average 1/17 — of the body
weight. It does not vary much. Marked vari-
ations occur during hemorrhage or during in-
fusion. Provided the other 3 factors remain
constant, any addition to the , amount of the
circulatory blood must lead to an increase in
blood pressure, and vice versa.
The elasticity of the vascular system pre-
sents itself as an alternate distention and elas-
tic recoil of the vessel wall, and is due very
largely to the connective tissue framework.
The aorta is not equipped with muscle cells
and merely serves the purpose of an elastic
reservoir, the recoil of which is largely re-
sponsible for onward movement of the blood
during the resting period of the heart. When
the elastic property of the vessels is diminished
by infiltrations, the pressure must rise ; con-
trariwise, any unusual relaxation of these ves-
sels must lower the pressure.
The principal factor concerned in forming
the peripheral resistance is the size of the
arteriocapillary outlet. The arterioles are
heavily beset with smooth muscle tissue which
on account of its contractile power is able to
diminish, sphincter-like, the outlet into the
capillary system. This part of the vascular sys-
tem serves the purpose of a gate which may be
closed or widely opened. If it is closed, the
arterial blood is hindered in its escape into
the capillaries and the arterial pressure rises ;
if it is opened, more copious escape of the
arterial blood diminishes the arterial pressure.
It is a simple matter to analyze changes in
blood pressure when only 1 of the 4 factors
mentioned is affected. As a rule, however,
the changes produced by one are modified by
those produced by a second or even a third
factor. Thus, it frequently happens that an
increase in energy of the heart, which ordi-
narily would result in a rise in blood pressure,
is compensated for by a lessening of the peri-
pheral resistance. The reverse is also true. It
is a well known fact that a vasoconstriction
which would otherwise lead to a higher blood
pressure, is often offset by a lessened fre-
quency of the heart and ventricular discharge.
A loss in the total quantity of the blood which
should reduce the pressure, is often compen-
sated for by vasoconstriction, i.e., by an in-
creased peripheral resistance. Examples which
could be mentioned to illustrate this interac-
tion are in reality too numerous to include
in this brief discussion.
What is true of these normal interactions
is also true of the abnormal ones. Let us
look for a moment at an outline of the more
common types of hypotension and hyperten-
sion :
Hypotensions. Functional : Chronic val-
vular disea'ses of the heart ; irregularities in its
beat ; hemorrhage ; vascular relaxation as in:
neurasthenia ; and shock. Organic : Loss of
constrictor substance, as after destruction of
adrenal bodies.
Hypertensions. Functional: Diet, excessive
weight, obesity; habits of life and physical
efforts ; menopause ; hyperthyroidism ; chronic
valvular diseases of the heart. Organic : Ar-
teriosclerosis, local and general ; diseases of
the kidneys.
It is now a simple matter to analyze any of
these conditions in accordance with the out-
line given above. Let us take, for example,
the hypotension of neivous debility and ex-
haustion. The chief factor is lessening of the
peripheral resistance by vasorelaxation. The
fall in blood pressure is reflexly compensated
for by an increase in energy of the heart. The
frequency of contraction is increased in order
to. augment the ventricular output, thereby en-
deavoring to retain an efficient pressure.
Quite similarly, we may select samples of
hypertension which may be arranged causa-
tively in accordance with the preceding table.
Mitral stenosis is usually associated with a
hypertension. A young person, exhibiting a
pressure of 140 to 150 mm. Hg., may be sus-
pected immediately of being afflicted with an
obstruction at this orifice. Nature endeavors to
counteract this hindrance to the ventricular
output by increasing the energy of the heart.
This organ beats more frequently and in-
creases its force of ejection. The early dilata-
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
tion of the left auricle is superseded by an
hypertrophy of its wall. In its endeavor to
propel the required amount of blood the heart
slightly overdoes it, and the result is an ar-
terial pressure somewhat above normal.
Local and general sclerotic changes of the
vessels invariably lead to a hypertension,
which increase in pressure can make itself felt
only after the compensation resident in a re-
duction of the cardiac energy has failed. Thus,
the high pressures (180 mm. Hg.) usually
present in people of about 70 years of age
have their cause, as a rule, in a general ar-
teriosclerosis which has passed beyond the aid
of cardiac energy. Never try to lower this
pressure, because a perfectly serviceable
hypertension may then be changed into a ter-
minal hypotension either by a loss of the car-
diac energy (heart failure) or an excessive
reduction in the resistance.
The hypertension of a hyperthyroidism
finds its origin in an increase in the peri-
pheral resistance. The latter is due to a spas-
tic setting of the vessels in consequence of
thyroid toxin. Later on, the initial hyperten-
sion may give way to a hypotension provided
the heart has been affected sufficiently to cause
an irregularity in its beat and atonia of its
muscle tissue. The hypertension of the meno-
pause has a similar cause.
The hypertension of obesity may be traced
to an increased peripheral resistance and
cardiac energy brought about by the fact that
the extra capillary expanse has overloaded
the circulatory system. Additional pressure is
required to provide an efficient circulation.
These few examples, I hope, will prove my
contention that the abnormal blood pressures
have as definite a cause as the normal ones.
Thus, if we restrict ourselves to solid basic
principles, such conflicting terms as essential
need not be employed at all. They only serve
to complicate matters. Analyzed in the above
manner, any type of blood pressure, whether
high or low, normal or abnormal, must as-
sume a more plastic and simple aspect.
PRACTICAL MANAGEMENT OF
DIABETES*
James Ralph Scott, M.D.,
New York City
Management of the diabetic patient resolves
itself into a consideration of 2 distinct mani-
festations of the disease — acute and chronic
diabetes.
Acute Diabetes with Coma
The classic signal of the acute diabetic is
coma, resulting from one of the following
causes: (1) dietetic irregularities; (2) sudden
withdrawal of insulin; (3) infections; (4)
acute surgical conditions, such as appendicitis,
cholecystitis, or carbuncle.
The symptoms associated with diabetic coma
are: (1) nausea and vomiting; (2) abdominal
pain; (3) rapid, shallow respiration, or air
hunger; (4) subnormal temperature, unless
complicated by infection; (5) soft eyeballs
(almost pathognomonic) ; (6) acetone breath;
(7) albumin and casts in the urine; (8)
anuria, as contrasted with polyuria of the pre-
comatose state; (9) sugar and acetone bodies
in the urine; (10) high blood sugar, low
plasma CO, nitrogen retention, urea nitro-
gen 50 mg. per 100 c.c. ; (11) coma.
Whether the condition be an uncomplicated
coma due to overindulgence in food, or one
brought on by infection, or one complicating
an acute surgical condition, the treatment is
the same. The condition should be regarded
as an emergency and, if possible, the patient
taken immediately to a hospital.
A known diabetic who is the victim of an
infection or who develops a fever from any
cause should be regarded as in impending
coma, and should be treated vigorously from
the start to forestall the threatened onset of
acidosis.
The patient should of course be put to bed,
with a nurse in constant attendance. If con-
scious, hot tea, coffee, broth, orange juice, or
water should be given every hour in 6 oz.
•(Address delivered before the Passaic County
Medical Society, September 11, 1930.)
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
305
amounts ; he should be kept warm ; a com-
plete enema followed by a retention enema of
1 pint normal saline; if there is evidence of
gastric distension, lavage should be done.
If the patient is actually in coma, hot cof-
fee or normal saline (6 oz.) should be given
by rectum every 3 hr. and supplemented by
hypodermoclyses of 1000 c.c. physiologic sal-
ine every 6 hours. With suppression of urine,
an infusion of 1000 c.c. saline twice daily is
the best possible diuretic. Caffein sodium
benzoate gr. 71/ 2, should be given subcutan-
eously every 2 hours. If the pulse is rapid
and of poor quality, digifolin should be given
intravenously, gr. 1^4, every 4 hours till an
effect is noted.
All the above measures are directed toward
correcting 3 conditions that invariably ac-
company a coma of diabetic origin, namely:
(1) extreme desiccation of the body tissues;
(2) circulatory collapse; (3) urinary suppres-
sion.
To overcome the high blood sugar and elim-
inate acetone bodies from the blood, insulin
is the remedy par excellence. If the blood
sugar, on admission, is over 500 mg. per 100
c.c. and the CCA is below 25 volumes per cent.,
give 40 units of insulin intravenously at once,
to be followed by 20 units subcutaneously. Re-
peat the 20 units subcutaneously every hr.
until the urine sugar is reduced to a faint
trace and the blood sugar is below 200 mg.
At first the blood should be examined at
hourly intervals for sugar, urea and CCA A
catheter should be inserted and kept in place,
and the urine tested every y2 hr. for sugar,
acetone and diacetic acid.
In from 2-6 hr., with this intensive treat-
ment, the acidosis should be under control.
During this time no glucose is required either
by mouth, rectum or intravenously ; the pa-
tient already has too much glucose in his blood
and his tissues are saturated with it. At St.
Luke’s we have abandoned giving glucose to
patients in the early intensive treatment of
acidosis. Formerly, when it was given, the
second and third blood sugar determinations
were frequently higher than the first, and re-
covery was only delayed. What the patient
needs at this stage is plenty of fluid to over-
come desiccation of the tissues and promote
elimination, and adequate amounts of insulin
to neutralize the acidosis. The reason glucose
was formerly given was, of course, the fear
that not enough glucose existed in the body
to oxidize" the excessive fatty acids circulating
in the blood. When successive blood sugar
determinations showed, however, that even
with insulin additional glucose only increased
the blood sugar, this practice was discontinued.
With hourly or even two-hourly blood sugar
determinations and half-hourly urinalyses
there is no danger of insulin reactions. There
is usually more than enough sugar already in
the tissues to remove the excess fatty acids
provided insulin is given in adequate amounts.
We now accomplish in a shorter time, with
smaller doses of insulin given more frequently,
without glucose, what formerly we accom-
plished over a longer period of time with
larger doses of insulin and additional glucose.
The patient needs in the first 24 hr. of treat-
ment 50 to 100 gm. of glucose, but this is be-
gun only after the body fluids have been re-
stored and the blood sugar has fallen to at
least below 200 mg. per 100 c.c. By that time
the patient is probably conscious, and fluids
can be taken by mouth. As soon as the urine
becomes sugar-free, give 4 oz. orange juice
by mouth at once. The patient can now be
regarded as out of coma.
Acute Diabetes Without Coma
At St. Luke’s we have a definite routine for
patients who have traveled thus far on the
road to recovery. I have devised what is
known among the members on the staff as the
B and O diet : buttermilk and orange juice al-
ternating in 6 oz. amounts every 2 hr. for
16 of the 24 hr., making a total of 4 glasses
of each in 24 hr. ; it is not given during the
night. This diet is supplemented by water,
tea, coffee or broth, so that the patient re-
ceives a glass of fluid every hour. This diet
contains C 122, P 21, F 7 gm., and amounts
to 641 calories. Being relatively high in C
and low in F, it is an ideal diet for combating
acidosis. If the patient dislikes buttermilk,
skimmed milk is given instead.
At this stage the blood is examined once
daily for sugar, urea, and CCA If acetone
disappears from the urine, but the blood CCA
306
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
remains low , it is probably due to some un-
identified organic acid. In this case the CO
will return to normal if soda bicarbonate is
given in small amounts; 30 gr. t. i. d.
The urine is examined -with Benedict’s quali-
tative solution every 3 hr., and insulin given
according to what is called the color formula :
If the test is orange, 15 units of insulin.
If the test is yellow, 10 units of insulin.
If the test is green, 5 units of insulin.
If the test is blue, 4 oz. of orange juice.
Ibis is absolutely a fool-proof formula, and
can be followed literally without danger to the
patient. I first saw it in use on Dr. Joslin’s
service at the New England Deaconess Hos-
pital, in Boston. It now has the status of a
ward order at St. Luke’s Hospital, and works
perfectly.
If the patient is obese, he is kept on this
reducing diet — with the necessary insulin —
foi several days or even a week or more while
he is in bed. The urine is then tested 4 times
daily — before breakfast and 1 hr. after meals
and insulin is given before meals in the
usual way. A blood chemistry is done twice
weekly while in the hospital. If the urine be-
comes sugar-free, the noon insulin is reduced
2 units a dose until none is being taken at
that time. Then the night dose is reduced ; and
finally, if the urine remains sugar-free and
the blood sugar becomes normal, the morning
dose is reduced or eliminated.
At least a week before the patient leaves the
hospital, a maintenance diet is prescribed. An
average diet on discharge is about as follows:
C 120; P 75; F 110; 1770 calories. Approxi-
mately 1/3 of the surgical diabetics leave the
hospital without insulin.
The Ambulatory or Chronic Diabetic
After the patient is discharged from the
hospital he joins the ranks of the chronic dia-
betics, and requires management of an en-
tirely different character.
The criteria by which the success of the
treatment may be judged are:
(1) A sugar-free urine.
(2) A normal blood sugar; fasting sugar
below 125 mg. per 100 c.c. ; after meals sugar
below 170 mg. per 100 c.c.
(3) A weight 10% below average for age
and height; tables for these weights are mere-
ly approximate, but nevertheless serve as an
extremely useful guide.
If these conditions are met, the patient is
being adequately treated. The chief instru-
ment in accomplishing this is education of the
patient. In the Diabetic Clinic at St. Luke’s
each patient, or some member of the family,
is taught to do 3 things: (1) Test the urine
for sugar, using Benedict’s qualitative solu-
tion. (2) Calculate his diet. (3) Give him-
self insulin, this can be done anywhere, and
the equipment required is simple: a test tube,
a medicine dropper, a bottle of Benedict’s
qualitative solution, a 500 gm. food scale, and
an insulin syringe with insulin. With a very
little patience, this training is not so formid-
able a task as it might appear to be. By ac-
tually performing a sugar test before the pa-
tient he can learn to do it in 5 minutes. All
except the mildest cases are placed on weighed
diets fiom the first. I his often necessitates
a struggle, but the effort expended will be re-
paid many times in the increased interest of
the patient once he has mastered the intrica-
cies of this fascinating subject.
I often tell my patients that one reason I
enjoy treating diabetics is that the patient does
all the work. 1 he routine of a clinic patient
who is taking insulin would be as follows, and
this applies to private patients as well as clinic
patients.
(1) He tests his urine before breakfast
and 1 hr. after each meal. A daily record of
this is kept and brought to the clinic on each
visit. \\ e rarely do 24 hr. determinations
now. The 4 daily tests are more reliable in-
dices of how much insulin is required and at
what time of day it is most needed.
(2) He weighs all his food until he has
become familiar with the prescribed amounts
of each ; is then allowed occasionally to dine
at a restaurant where he has to estimate the
quantity of food, after which he does a urine
test to see how close he came to his allowance.
This can become a fascinating game.
(3) He gives himself insulin. After fol-
lowing the effects of insulin on his tests, he
is allowed to increase or decrease the insulin
1 unit a dose as indicated by his tests.
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
307
(4) He visits the clinic anywhere from
once a week to once a month, depending on
the severity of his case. A well trained pa-
tient not on insulin need not come oftener
than once in 2 or 3 months. Blood sugar de-
terminations are done at least 4 times a year.
At the clinic a specimen is examined for sugar
and acetone ; the patient’s weight is taken and
recorded on his chart to compare with his
theoretic normal ; and instructions given as to
diet and insulin.
Insulin
Of the patients in the clinic 30% are using
insulin; amount varies from 5 to 120 units a
day; number of doses varies from 1 to 4 a
day. The insulin is usually given about 20
minutes before the meal ; in some instances as
long as 2 hr. before. If 1 dose, it is given be-
fore breakfast; if 2 doses, before breakfast
and dinner ; 3 doses, before breakfast, lunch
and dinner ; 4 doses, before the 3 meals, and
a small dose, from 3 to 5 units, is given at
bedtime. When cutting down on the number
of injections per day this order is reversed.
I am often asked how to determine the
quantity of insulin required in each individual
new case. There is no infallible rule. Any
patient showing sugar in the urine can start
with 5 units of insulin before breakfast. If
sugar appears in the urine after the other
meals, he can take 5 - 5 - 5 ; i. e., 5 units
before each meal, running the dosage up or
down until the necessary quantity is being
given. By varying the dosage according to
tests of the 4 daily single specimens, an equi-
librium is soon reached. Keeping the urine
sugar-free appears to improve the patient’s
tolerance. After a week of sugar-free urine,
therefore, the diet can gradually be increased
or the insulin decreased. With a thin person
the former procedure would be adopted, and
with a fat person the latter.
A certain quantity of insulin given 3 or 4
times a day is more effective than the same
amount given only once or twice a day, with
less risk of an insulin reaction. A patient was
referred to me recently who was taking 80
units of insulin daily — 40 B — 40 D on a carbo-
hydrate allowance of 170 gm. — a severe dia-
betic. He frequently suffered from insulin
reaction, and showed sugar in his urine on
one or more of his 4 daily tests. By redis-
tributing his insulin so that he was taking a
dose before each meal and 3 units at bed-
time (11 p. m.) he became sugar-free on all
his tests and had no more insulin reactions —
and this was accomplished on 60 units per day,
as contrasted with the 80 units he was pre-
viously taking, with no change in his diet.
Insulin reactions are comparatively infre-
quent in adults. In children they are com-
mon. Every child taking insulin of 10 units
or more a dose should carry 2 lumps of sugar
or an orange to be used in such emergencies.
If insulin is taken at all it must be used daily.
Patients who test their urine 4 times daily, and
vary their insulin accordingly, rarely suffer
from insulin reactions. At the most, insulin
reactions are disagreeable rather than danger-
ous.
Liver has recently been added to the dia-
betic diet. It is an insulin saver ; lb. liver
a day will take the place of from 5 to 10 units
of insulin. I have a private patient who has
been taking liver for 3 months with gratifying
results. With no other change in diet he has
been able to reduce his daily insulin from 10
units t. i. d. to 5 units once a day, without
showing sugar in the urine and with no ele-
vation of the blood sugar. Whether or not
this marked improvement can be attributed
entirely to liver, I do not know, but it certainly
has helped. After 3 weeks of the liver diet
the patient balked but since giving him before
2 of his daily meals a well seasoned broth
prepared from fresh liver, he has taken it
willingly and has thrived on it. The broth is
prepared by macerating ^4 lb. liver (it can be
put through a meat chopper), and steeping
it for an hour in warm water. The pulp then
squeezed into the water and the broth set
aside in the icebox to be served as required.
The preparation is not boiled, aS boiling de-
stroys the insulin-saving principle.
Another insulin saver is exercise. A good
vigorous walk will use up a considerable
quantity of sugar and allow the insulin to be
decreased accordingly. Two walks of Yz hr.
are better than 1 walk of an hour. Patients
are encouraged to experiment with exercise as
they do with food and insulin to determine
3 08
April, 1931
JOURNAL OF THE MEDICAL
their tolerance. Unusually prolonged or vig-
orous exercise in a diabetic using insulin will
produce insulin reactions unless the insulin is
reduced from the usual amount. In a diabetic,
exercise is a drug second in potency only to
insulin and food.
After insulin, the next most confusing as-
pect of treatment of this disease is the diet.
Except in the mildest cases all foods at first
should be weighed. This accomplishes 2
things : ( 1 ) Educates the patient in the funda-
mental principles of treatment of his disease,
and this is extremely important. (2) Increases
cooperation of the patient. In all our cases in
which the patient has made a serious attempt
to calculate his diet, it has evidently aroused
his interest and resulted in more complete co-
operation with his physician.
There are 3 types of patients to consider:
obese, thin, and children. Obese patients
can usually be rendered sugar- free on an un-
der-nutrition diet alone. The buttermilk and
orange juice diet already mentioned is an ex-
cellent reducing diet provided the patient can
be put at rest. Any reducing diet should be
as low as possible in fat. Reduction can be
accelerated by using insulin, although at first,
due to water retention, there may be no ap-
parent loss in weight.
With malnourished individuals, however,
and children, no attempt should be made to do
without insulin. They need to build up
strength and promote growth. Therefore, ade-
quate diets should be prescribed at once and
enough insulin given to handle them. Children
require from 40 to 50 colories per kilo body
weight, and 3 to 4 grams of protein per kilo.
For dietetic instruction the patients fall into
2 categories: (1) Mild cases require only
general directions about diet. (2) Those with
moderately severe and severe conditions are
taught to weigh their diets, or at least to
measure them* i. e., to calculate them by the
cupful and tablespoonful, instead of by the
gram.
Patients in mild condition are merely told to
avoid sweets, starches, butter, oil or fat, and
anything made with flour. They can usually
stand a little reduction in weight, which this
so-called “restricted diet” will accomplish.
1 hat leaves the patient on a diet consisting
SOCIETY OF NEW JERSEY
mostly of vegetables, meat, eggs, milk in mod-
erate amount, cheese, and all but the particu-
larly sweet fruits, but he is of course instruct-
ed to eat moderately even of the foods allowed.
If vegetables are restricted to the 5% variety
and fruit limited to grapefruit and oranges,
the patient would have difficulty in eating
more than 100 gm. C. in a day. Of course
broth and tea or coffee without cream or sugar
are allowed in unlimited amounts. Water
drinking should be encouraged. A few days
to a week on this diet will render the urine
sugar-free. Bread is then allowed in increas-
ing amounts up to a reasonable number of
slices a day, one at each meal. It is well to
maintain a moderate restriction of fats and
sweets at all times, and to guard constantly
against overweight.
I hose in severe or moderately severe cate-
gory are first placed on one of Toslin’s main-
tenance diets ; the food to be weighed directly
on the food scale without calculating the C.,
P. and F. food content. Later, as the pa-
tient acquires more confidence, he is trans-
ferred to a formula, and can vary his diet at
will; i.e. his C., P. and F. for the day are pre-
scribed and by calculating these values for
the foods he selects he can arrange his diet to
suit himself.
Nowadays every diabetic about his usual
daily life should be taking at least 100 gm. C.
per day. None of my patients are taking
more than 190 gm., and the average is about
120 gm. The protein requirement is 0.67 gm.
per kilo body weight, and fat enough to bring
the diet up to caloric requirements — 30 cal-
ories per kilo. 4 he fat rarely exceeds the
carbohydrate, whereas in the beginning of
the insulin era it was usually 2 or 3 times the
carbohydrate. In those days patients who were
treated most scientifically according to our
knowledge at that time were most apt to de-
velop acidosis, while now acidosis in a well
treated case is rare.
I he surgical diabetic is a special problem
and requires careful pre-operative and post-
operative treatment. If time permits, 7-10
days should be devoted to preparing the pa-
tient for operation. The buttermilk and or-
ange juice diet plus insulin will accomplish
this in the allotted time. Fluids should be given
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
309
freely, over 100 oz. per day, and should be
continued up to 1 hr. before the operation ; 6
oz. orange juice with 10 units of insulin are
given 3 hr. before the operation; and after the
operation 500 c.c. saline is given by clysis and
fluids — broth, water, orange juice — are given
by mouth as soon as they can be retained.
About 100 gm. C. should be given during the
first 24 hours. The buttermilk and orange
juice diet is employed routinely for the first
2 or 3 days post-operative. It has been shown
experimentally, however, that healing of a
wound is retarded by a diet too low in protein ;
hence, after the third day a diet is prescribed
containing at least 1 gm. protein per kilogram
body weight, and is continued until the pa-
tient is discharged.
The acute emergency surgical case on ad-
mission to the hospital is practically always
on the verge of coma, if not already in coma.
These require the prompt and vigorous meas-
ures already described under treatment of dia-
betic coma. An immediate infusion of 500 to
1000 or even 2000 c.c. saline is given, and in-
sulin in half-hourly or hourly intervals as in-
dicated by the blood and urine analyses. In
as short a time as 2-3 hr. the acidosis may be
sufficiently under control to permit the opera-
tion. The anesthetics of choice are either
local, gas-oxygen, or spinal. Ether should
be avoided as it tends to damage the liver and
increase acidosis.
Finally, as you all know, infection of any
kind is bad for a diabetic. The first break-
down in S. tolerance is often initiated by an
infection. Infection causes a mild case to
become severe, at least temporarily, and is
frequently fatal to a severe case. Therefore,
care should be taken to remove obvious foci
of infection ; particularly the teeth should be
x-rayed, and those teeth showing apical ab-
scesses should be removed. Infected tonsils
should be removed.
Particular care also should be devoted to
the feet. Arteriosclerosis is more marked in
diabetics than in others, and it occurs earlier
in life. I have .seen in a diabetic girl of 17
arteries so calcified that they cast a shadow
on an x-ray film. Hence, abrasions and injuries
to the feet are slower to heal, with the conse-
quent onset of gangrene. This condition is
easier to prevent than to cure.
HEREDITARY EPISTAXIS; WITH AND
WITHOUT HEREDITARY (FAMILIAL)
MULTIPLE HEMORRHAGIC
TELANGIECTASIA* *
Hyman I. Goldstein, M.D.,
Camden, N. J.
Since I published my paper on “Hereditary
Hemorrhagic Telangiectasia with Familial
Epistaxis” in the Archives of Internal Medi-
cine, January 1921, a number of excellent re-
ports on “Hereditary Nosebleed”, “Familial
Hemoptysis”, “Familial Hematuria”, “Osier’s
Disease”,** “Hemorrhagic Telangiectasia”,
gastric, rectal, and renal bleeding of unex-
plained etiology, have appeared in the medical
literature of the world. Most of the papers
were published in the medical Journals of
Germany, France, England and only a few
in America. In study of the subject of “Epi-
staxis”, I reviewed the medical literature for
the past 300 years, but especially reports pub-
lished since 1830.
Nosebleed, or epistaxis, has been an im-
portant subject for discussion since Biblical
times. It was one of the earliest complaints
treated by medical men and healers. Hippoc-
rates (450-357 B. C.) in Epidem. Lib. I.
Aphor. 33, spoke of vicarious menstruation
(rhinorrhagia) through nosebleed, remarking
that those who have confirmed nosebleed into
a habit are young persons apt to incur diseases
of the chest, pleuritis, pneumonitis, hemoptysis
and consumption, probably owing to a metas-
tasis of the nasal irritation to the lungs, but
such not taking place, it is held to have a con-
*(Read at the Annual Meeting of the Medical
Society of New Jersey, Atlantic City, June 13,
1930.)
* * The following terms here used as eponyms
and synonyms: Osier’s Disease; Rendu-Osler
Weber Disease; Ullmann-Goldstein’s Hereditary
Angiomatosis with Hemorrhages; Hereditary
Hemorrhagic Telangiectasia with Familial Epi-
staxis and other hemorrhages.
310
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
trary, or preventive, effect of pulmonary af-
fections.
Nasal hemorrhages may be very profuse,
Johannes Rhodius (1587-1659) of Padua, in
his Observationum Anatomico-Medicarum
Centuriae Tres (1657, I b, also Frankf. 1676),
mentions a patient losing 18 lb. of blood with-
in 36 hours. Bartholin’s patient lost 48 lb.
and a writer in the Leipsic Acta Erudita men-
tions a patient losing 75 lb. within 10 days.
The Ephemera of Natural Curiosities contain
a case report in which the patient bled from
the nose without cessation for 6 weeks. In
1820, Professor Chapman treated an elderly
gentleman who lost several quarts of blood
and mentions 2 persons who bled to death.
Claudius Galen (131-200 A. D.), Coschwitz
(1616), Fabricius Hildanus (1560-1640),
Friedericus Hoffman (1660-1742), Sebizius
(1630), Kau (1710 Jena), Block (Jena,
16/9), J. Rhodius (1587-1659), Henricus
Petraeus (1589-1620), Samuel Rumpler
(1615), Taunton (1830), Sutton (1864),
Babbington (1865), Albert Rosenberg (1900
Berlin- Vienna), and others too numerous to
mention, have discussed nosebleed or epistaxis
associated with various diseases and different
constitutions, and often leading to fatal re-
sults. Ihus, Albert Rosenberg, of Berlin, in
Handbuch Der Laryngologie und Rhinologie,
Vol. III., 2 Halfte, (by Professor Paul Hey-
mann, pages 697-722, Vienna, 1900), writes
on Das Nasenbluten giving 369 references
from Hippocrates, 400 B. C., to Hastings, De-
cember 1897. Friedericus Hoffmann (1740)
long ago remarked that persons with frequent
and profuse epistaxis when young, had a pe-
culiar constitution like that observed in
“bleeders”; also similarly discussed bv Lay-
cock in Medical Times, page 501, May 17,
1862 (London). Hoffmann observes — “ob-
servamus porro, omnes fere eos, quibus san-
guis copiosus et frequentius in primis annis
per nares erumpit, natura valde imbecilles,
animo quoque sensibiliores, varisque mor-
borum afflictionibus, spasmis et doloribus per
omnen fere aetatem subjectos esse ; rarius
etiam vitam diu protrahere; quippe in juven-
tute in phthisin inclinent, in consistente aetate
in malum flatulento-spasmodicum sive hypo-
chondriacum facile incident, atque aetate pro-
vectiori ad dolores nephriticos et podagricos
mul turn proclives sunt”. (Hoffman-Medic,
rational, systemat. Pars II. Sect. I, Cap. I u.
Opuse, physioco-medica p. 196, 1740.)
Thomas Laycock, of London (1862) in his
lectures on The Haemorrhagic Diathesis and
Haemoptysis says : “epistaxis is a symptom of
considerable significance, although generally
overlooked in persons of phthsical habits”. He
had often noted it as being premonitory of fu-
ture hemoptysis, and often, too, observed it as
coinciding with intercurrent attacks. In many
of his 227 cases of diathetic “bleeders” it was
noted that bleeding was nasal (about ^ the
cases) and he found that epistaxis, hemopty-
sis, hematuria, and hematemesis succeeded or
alternated with each other or were “meta-
static”. He emphasized the fact that epis-
taxis, repeated and profuse attacks about
puberty, in certain constitutions indicates a
tendency to hemoptysis and tuberculosis sub-
sequently.
Laycock, Chapman (1839), Sutton (1864),
and others believe there was a class of cases
in which the hemoptysis and the nose bleed
did recur from time to time rather as an here-
ditary or a rheumatic than a tuberculosis af-
fection, the condition being a “constitutional
epistaxis” or “hemoptysis”. Laycock (1862)
further speaks of mitral constriction as a
source of hemoptysis and epistaxis and their
close relation to rheumatism. He empha-
sized the hereditary relationship of nosebleed
and blood-spitting. He concludes by saying
that the hemorrhagic diathesis presents many
of the peculiarities of the rheumatic or gouty,
whether we regard the age, sex, hereditari-
ness, tendency to, articular affections, or the
exciting causes of the periodic or paroxysmal
bleedings.
Hoffman (1740), Taunton (1830), Chap-
man (1839), Babbington (1865), Rosenberg
(1900), Frohlich (1891) and many of the
other older writers recognized the importance
of heredity in relation to repeated and habit-
ual nosebleed. It has also been emphasized
that attacks of nosebleed frequently precede
attacks of acute rheumatic fever.
Chapman, who was Professor of Physic,
University of Pennsylvania, prefers the term
“hemorrhagia nasi” to “epistaxis” (Medical
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
311
Examiner, Phila., Feb. 23, 1839, II, No. 8, p.
117-118). Rosenberg (1900) prefers the term
“hemorrhagia narium” or “rhinorrhagia”.
Chapman says (Jan. 5, 1839) those with short
neck and large head are prone to have epis-
taxis or apoplexy, while those with a narrow,
ill-shaped chest, are equally subject to hem-
optysis. Nor is it uncommon for whole families
to be thus distinguished, and who, in some in-
stances, seem to derive the peculiarity by in-
heritance. He refers to instances reported in
Andral’s work on Pathologic Anatomy, and in
an essay on the subject by Dr. Reynell Coates,
in the North American Medical Journal. He
mentions the writings of Morgagni, Bichat
(Anatomie Generale), and Marendel. Mar-
Fig. 1. — Telangiectases on the face. The family
tree of this patient is given in Figure 3
(Family 28, Steiner 1, III, 22).
Dr. Goldstein — Telangiectasia.
Steiner: Archives of Internal Medicine, 1917.
endel found no ruptured blood-vessels in these
fatal cases of vital (spontaneous) hemor-
rhages even with the microscope. Chapman
says “the dermoid usually effuses in the shape
of petechiae or vibices, or what is called
hemorrhea purpurea”. Aristotle, Theophras-
tus, Lucan, and Huxham speak of these
hemorrhagic “spots”. I am of the opinion
that these old writers saw cases of epistaxis
with telangiectatic skin and mucous membrane
lesions.
C. Hanfield Jones (Medical Examiner,
London, I, Nos. 46 and 47, p. 806 and 823,
Nov. 16 and 23, 1876) in his Clinical Lectures
on Epistaxis does not mention telangiectasia
and familial epistaxis. He says, however, that
“in these hemorrhages, the deterioration of the
capillaries seems to be the essential morbid
change”.
Valsalva knew that nosebleed occurred more
often from the anterior portion of the septum
(des knorpeligen septums), and also that “san-
guifera vasa intra nares valde turgida circa earn
sadem, ubi alae nasi digito plus minus trans-
verso ab imis naribus cum osse committuntur”.
Dr. Marvin, of Geneva (Jour, de med. et de
chirurg. practique, 1872) stated that as blood
in epistaxis generally came from only one nos-
tril, and most frequently from the anterior
third of one of the nasal fossas, he was led to
believe that by compressing the corresponding
facial artery on the superior maxillary bone
near the ala of the nose, the afflux of blood
would be diminished and the hemorrhage at
once arrested.
Dr. Brunner (Huf eland’s Journal) stopped
epistaxis by blowing powdered gum arabic
through a quill into the nose. In the Phila.
Monthly Jour. Med. and Surg., I, No. 2 p.
102, July 1827, a case is reported of a young
man aged 19, who continued to bleed until
stopped by this method.
Fabricius (Guilhelmus) Hildanus (1682),
in his op. observ. et curat, med chir., reported
a young married man who had severe nose-
bleed after each coitus.
J. Rodius mentioned nosebleed following
smelling a rose.
T. A. Flail (Virginia Medical Monthly,
1896) says the powder of fungus myces (F.),
commonly known as “devil’s snuff”, has in-
variably stopped epistaxis when snuffed up
the nostrils.
In “Epidemics”, Liber I, in the Third Con-
stitution, Paragraph VIII, Section 2, Hippoc-
rates speaks of epistaxis as one of the 4
modes by which ardent fevers came to a crisis.
When in these attacks of ardent fevers there
was a proper and copious hemorrhage from
the nose, they were generally saved by it,
and “I do not know a single person who had
a proper hemorrhage who died in this consti-
tution”. The hemorrhages attacked most per-
sons, but especially young persons and those
in the prime of life, and the greater part of
those who had not the hemorrhage died. In
certain individuals, he says, both the hemor-
rhage from the nose and the menses appeared
at the same time.
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1S31
Winstead (1858) stopped severe nosebleed
by cold, wet applications to the scrotum.
Rosenberg (1900) says Hoffman recog-
nized the importance of heredity in cases of
nosebleed. He mentions a case of epistaxis
m a child whose father and 4 brothers suffered
from epistaxis. Among 27,000 patients of the
University Polyclinic for Throat and Nose
Diseases (Berlin), he found 367 instances of
nosebleed, of which 247 were in males and
120 in women. The largest , number occurred
in the period of puberty; 101 were between
15-20 years. He mentions a case of a young
girl aged 15, who had not menstruated norm-
ally but who bled irregularly from the nose,
and a woman who missed her periods for 5 or
o months without pregnancy and who had suf-
fered from epistaxis for 6 weeks when she was
seen by Rosenberg. He found nosebleed to vary
with climate and seasons — the largest percent-
age of cases occurred in May, June and July.
Obermeier mentions an interesting case in
a young man who had bled from the nose
every month for 3 days since the age of 15
j'ears.
Rosenberg mentions severe nosebleed at
times after postoperative menopause.
Hubbard reports a pregnant woman who
died from profuse nosebleed.
Urbantschitsch, Taubhert and Blondeau
noted pregnant women wdio aborted after
nosebleed.
Blondeau (Gaz. des Hop. nr. 149/51
1874) recorded a case of a pregnant woman
who aborted following blood transfusion for
epistaxis.
Under the term “nosebleed” or “epistaxis”
(nasenblueten) as used in this paper, I in-
clude bleeding from the nose, the source of
which is to be found in the nose. Bleeding
from the nose, as may occur in hematemesis,
hemoptysis, postoperative (tonsillectomy and
adenoidectomy) conditions, vegetative aden-
oids, ulcerations and new growths of the naso-
pharynx, middle ear bleeding, fracture of the
base of the skull, etc., is not included. Nor
am I considering the numerous other causes of
nosebleed in general diseases.
I limit myself in this paper to a discussion
of a definite clinical entity, namely, cases of
hereditary (familial) nosebleed occurring in
rami lies and often associated with telangiec-
tatic lesions of the skin and mucous mem-
branes.
Cases of nosebleed in several members of
a family may occur, without a definite his-
tory of the presence of telangiectasia. How-
ever, in some instances, as well as shown by
Fitz-Hugh (1923), other members may be
thus affected (with skin lesions) in future
generations. He believes an atavistic tendency
m this condition has been demonstrated, hav-
ing noticed atavistic skipping of a generation
in 7 cases. Foggie’s family shows this atavis-
tic tendency.
Gossage believes that in some of these fam-
ilies many of the children die young, before
an opportunity has been afforded to know
whether they would also have been similarly
affected — which accounts for fever affected
ones. He says “the condition of multiple
hereditary telangiectasis seems also to be a
dominant to the normal condition”.
Henle believes the condition acts as a simple
dominant with some variations.
It is also true, I believe, that cases of
familial hematuria (Apert 1907, Foggie 1928,
Attlee 1901, Pearson 1904, Aitken 1909, Guth-
rie 1902, Hurst 1923, and Grandidier),
familial hemoptysis (Libman and Ottenberg,
Dec. 1923. and Mantchik, 1922), familial
hemorrhagic nephritis— (Hurst 1923) and
hereditiary hemorrhagic telangiectasia, with
or without familial epistaxis, are all properly
classified under the same heading.
H. Gawen Sutton, Assistant- Physician to
the Metropolitan Free Hospital, in the De-
cember 1864 issue of the Medical Mirror
(pages 769-781) in a thorough manner dis-
cusses “Epistaxis as an Indication of Impaired
Nutrition, and of Degeneration of the Vas-
cular System . He emphasizes the important
part played by imperfect nutrition and de-
generation of the vascular (capillary) system,
and discusses the well-known fact that those
who bleed habitually from the nose are more
liable to certain diseases than others. Thus,
he shows that it frequently occurs in indi-
viduals subject to rheumatic fever, hemoptysis
and phthisis in adult life.
J. J. Kam (1745) in “De haemorrhagiae
nariutn in junioribus nimiae noxis” (Argen-
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
313
torati) also observed that there is a connection
between the epistaxis of youth and the
hemophysis and phthisis of adult life.
J. Haan 220 years ago, in ‘De hemorrhagia
narium” (1711, Argentorati) reported similar
experiences.
Lavcock (1862) stated that he has often
noted epistaxis as being premonitory of future
hemoptysis.
French, in his “De Curandis Hominum
Morbis”, stated “that young people who had
been subject to oft repeated nasal hemor-
rhage have to fear hemoptysis, and that hemop-
tysis is hereditary in some families, and those
liable to it may succumb in the flower of their
age to this hemorrhage or to consumption”.
Fig. 2 — Telangiectases on the tongue. The family
tree of this patient is given in Figure 3
(Family 26, Steiner 1, IV. 12).
Dr. Goldstein — “Epistaxis and Telangiectasia.”
Steiner: Archives of Internal Medicine, 1917
Chomel has stated in his essays on rheu-
matic fever that Hippocrates said, in the end
of the second volume of Prorrheticon, that
those who had been subject to epistaxis in
their childhood and youth were particularly
predisposed to arthritic fevers. Chomel found
that 1/3 of those who had rheumatic fever
had previously suffered with nosebleed.
Sutton (1864), too, has found that of 31
patients suffering from rheumatic fever, 21
previously had epistaxis. There are patients
who have previously suffered from -rheumatic
fever who later have repeated attacks of epi-
staxis. He reports the case of a lady, age 74
years, who had severe attacks of hemoptysis
and bled profusely from the nose when a
young girl, and another woman aged 46 years
who had bled from the nose when a child and
now was suffering from hemoptysis ; her
father suffered from a “ruptured blood-vessel
of the lungs” and hemoptysis ; an only brother,
who died of inflammation of the lungs, also
had hemoptysis and for a number of years
before his death often bled profusely from the
nose; her 3 sons all bled from the nose; an
only daughter, aged 28 years, had never had
attacks of epistaxis. Sutton reports a second
family in which there were 3 brothers who
had nosebleed; one who died at 31 years of
age, bled profusely from the nose for many
years before he began to spit up blood
(“pints”) ; another who had suffered from
epistaxis was later laid up with rheumatic
fever. Sutton says the belief that epistaxis is
hereditary in some families has been asserted
by so many physicians that it would be diffi-
cult not to believe that it is so. It is import-
ant to remember that there is a connection be-
tween epistaxis of youth and rheumatic fever,
valvular disease, hemoptysis and phthisis of
adult life.
Hoffmann, also, has stated that those who
suffer with frequent and copious epistaxis in
early years are often subject in youth and
adult life to hemoptysis and phthisis, and mid-
dle age to gravel and gout.
Sutton tabulates 83 cases of phthisis of
which number 55 had epistaxis at some
periods of their lives. He also found that
during phthisis epistaxis often occurred be-
fore the hemoptysis.
J. C. Taunton (Article III, June 1830, p.
489, IV, No. 24, London Med. and Surg.
Jour.), Surgeon to the City of London Dis-
pensary, reported his own case of recurrent
epistaxis for 20 years. Llis parents were ap-
parently healthy.
Boenninghaus, of Breslau (1923), speaks
of habitual nosebleeds in patients he has seen
off and on during 20 years, bleeding from
“vena liminis” and not from “locus kisselbach
of the septum”. He mentions that Valsalva
knew of this source of habitual nosebleed, and
stopped the hemorrhage by means of finger
pressure. Boenninghaus stopped the bleeding
point with the electric cautery or the chromic
acid bead.
Frohlich, of Cassel (1891, Der Artzliche
Praktiker), reported a young patient with re-
current severe nosebleed; a brother died from
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
epistaxis; his only sister bled profusely since
the first menstrual period ; no mention is made
as to the parents bleeding from the nose.
Korstakow ( 1886) mentions a case of
menstruatio precox with severe periodic epi-
staxis.
Fricker (1844) reports fatal nosebleed of
vicarious menstruation.
Barford (1926) reports 2 cases of recur-
rent gastric hemorrhage without organic lesion
and associated with other hemorrhages. In
1 case there occurred recurrent severe hema-
temesis with occasional epistaxis and hema-
turia.
Hurst (1923) reported 16 individuals in 3
generations suffering from hereditary familial
congenital hemorrhagic nephritis. These cases
were similar to Guthrie’s (1902) series of
congenital hereditary and familial hematuria.
Up to 1912, Hurst could only find records of
2 other families similarly affected. Since 1912,
he says (1923) he learned of 2 additional
families through Dr. W. W. D. Thompson, of
Belfast.
E. Libman and Reuben Ottenberg, of New
York (Dec. 15, 1923), reported 7 members
of a family suffering from rather profuse
hemoptysis at intervals for years, beginning
at puberty or in early adult life and not ser-
iously impairing the general health. Tuber-
culosis was excluded. No telangiectases
were seen in the upper air passages broncho-
scopically. No mention is made of telangiec-
tases in any other part of the body. In the
cases recorded the condition seems not to skip
generations. The coagulation time was normal.
Blood platelets were normal. They say that
“if the condition is due to telangiectases, they
must be localized in the finer bronchi or in
the pulmonary tissue”. They were unable to
find a report similar to theirs in the literature.
“Idiopathic familial hematuria”, reported by
Apert, is mentioned as perhaps being “com-
parable” with their cases.
It seems probable, according to F. Parkes
Weber, of London (1924) who has studied
this subject extensively, that “gastrostaxis”
cases, as reported by Sir William Hale White,
and I may add, those reported by Pons, Meine
and Blenkle (Feb. 1929), before our New Jer-
sey State Society, may have been of similar
telangiectatic origin. Pons, Meine and Blenkle
(Jour. Med. Soc., N. J., 26:143, Feb. 1929)
did not mention telangiectasia as a possible
cause for the hematemesis in their cases.
Foggie (Edinburgh Med. Jour. May 1928,
p. 280) of St. Andrew’s University and Dun-
dee Royal Infirmary, reports the case of a
woman, aged now 47 years, who suffered from
hereditary hemorrhagic telangiectasia with re-
curring hematuria. He was able to collect 41
reported families ; with his family making al-
together 42. He includes the 31 family groups
1 was able to collect from the literature of the
world up to 1920. inclusive, and reported in
January 1921. I did not include the cases of
familial nosebleed mentioned by Sutton
(1864), and Rosenberg (1900), and the case
reported by Professor Vincent Tanturri, of
Naples (Morgagni, XXI, Aug. 1879) under
the title of “Un caso di dermostasi venosa
generale ed idiopatica”. In this case no men-
tion is made of epistaxis or other recurrent
hemorrhages. The girl was 14 years of age
and had generalized telangiectasia.
Babington (1865), Rosenberg (1900),
Richardson (1917), Boston (1930), Goldstein
(1922), Lane (1916). Verneuil (1894), Frdh-
licli (1891), Griffin (1927), Blumenfeld
(1926), Sutton (1864), reported cases of
familial (hereditary) epistaxis. In 1922 I re-
ported several cases of recurrent nosebleed in
one family and recently I met with another
family in which several members (father,
sons and daughter) bled profusely from the
nose.
Foggie’s patient gave a history of nose-
bleeding in 5 generations associated with
telangiectases. She only occasionally bled
from the nose but bled from the urinary tract
for 20 years, due to these vascular dilatations.
T. C. Fox ( 1908) reported a case of bilat-
eral telangiectases of the trunk with a his-
tory of marked epistaxis in childhood and re-
cent rectal bleeding.
Erasmus Wilson, of London (Jour. Cutan.
Med. and Dis. Skin, London, III, p. 198-199,
1869), under “Clinical Memoranda” and the
subtitle of “Eruptive Angiomata” reports
a case of a publican, aged 30 years, who had
copious bleeding from the gums, epistaxis and
an eruption of red papules on the face, neck.
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
315
hands and arms — “Angeiktasia” or multipli-
cation and hypertrophy of the venous capil-
laries of the skin. He says “the case is very
rare” ; thought this was a sudden eruption of
“angieoma associated with hemorrhage from
the mucous membrane of the nose and mouth”,
hut fails to mention other members of the
family with this condition.
Kalischer (1901) reports a case of telan-
giectasia (angiom) of the face and “der
Weichen Hirnhaut” (Archiv. f. Psychiat, Ber-
lin, 1901, Bd. 34, pages 171-180).
R. H. Kennan, of Sir Patrick Dun’s Hos-
pital (April 30, 1902) reported a typical fam-
ily with telangiectasia and epistaxis, mention-
ing Osier’s report in the Johns Plopkins Hosp.
Bull., November 1901. Osier, however, over-
looked several previously reported cases of
familial epistaxis and of hereditary telangiec-
tasia. He includes several of these in his
second paper in the quarterly Journal of Medi-
cine (London), October 1907, with colored
plates of A. Brown Kelly’s (1906) case.
Rendu ( 1896) was the first to associate
the tendency to epistaxis with multiple telan-
giectases as manifestations of a distinct clini-
cal entity, now, however, frequently called
“Osier’s Disease”.
Time will not permit to review the addi-
tional cases reported from 1876 to 1930. Suf-
fice it to say, that Coe (1906) reported, er-
roneously, a case as hemophilia which was re-
ported as a typical case of “hereditary telangi-
ectasia” by Osier, and that since Legg (1876)
and Chiari (1887) reported their cases there
"have been reported a total of 65 families and
about 350 individuals suffering from heredi-
tary (familial) epistaxis with hemorrhagic
telangiectasia including my cases reported in
1921 (Arch. Int. Med.) and in 1922 (Jour.
Med. Soc. N. J., 1922 p. 50), and including
Kofler’s (1908) cases. Since the publication
of my first paper there have appeared a num-
ber of excellent reports on the subject. It
might be of interest to list all the typical and
atypical cases reported to date, but I shall
limit myself to the more easily accessible and
available reports.
Recently, Professor Rudolf Schoen, of the
Morawitz Clinic, in the University of Leip-
zig, reported 2 cases of “Familiare telangiek-
tasie mit habituellen nasenbluten” (affecting
4 generations), in the Deutsches Archiv fur
Klinische Medizin, Bd. 166, Heft )4, 1930.
A. Arrak (1925), of Masing’s Clinic, in
the University at Dorpat, Esthonia, reported
2 families with hereditary hemorrhagic tel-
angiectasia (Deutsches Arch. f. Klin. Med.,
147, June 1925, pp. 287-291).
Dore’s (1927) case of multiple familial
telangiectases was a woman, aged 56 years,
who had multiple telangiectases for 14 years.
She had them also on the tongue, lips, hands,
under one nail, a few on the body. She suf-
fered from frequent nosebleed. Her mother
had multiple telangiectases. Patient does not
know whether other members of the family
were similiarly affected. Electrolysis was
tried. Dore used carbon dioxide snow. This
was the third case of the kind he had seen.
One of the patients (a man) said that the
condition had been known in his family for a
hundred years. The third patient was a
young woman, but no other members of her
family appeared to be affected.
F. Parkes Weber, of London, discussing
this presentation, said that “though the tend-
ency was inborn, the lesions of the skin and
mucous membranes manifested themselves or
were often first observed at relatively late
periods. The nosebleeding, however, was
often noted earlier”.
R. A. J. Harper (Apr. 1929) reports the
case of a man, aged 45 years, who had hemor-
rhages from the nose, gums and tongue. He
had red “spots” on the cheeks and ears, ton-
gue, gums and palate. Epistaxis was fre-
quent. Stools were black at times. No blood
in urine. His father and a sister (47 years
of age) and her 2 young sons suffer similar-
ly. The patient himself has 7 children ; 3
sons are well, while 4 daughters are all af-
fected.
Willis C. Lane (Mar. 1916, University of
Maine) reports cases of “hereditary nose-
bleed”, but no mention of telangiectasia is
made.
Schwartz, of Minneapolis (1925), reported
a case in a woman, aged 49 years. She suf-
fered from severe nosebleed since the age of
14; also severe hemorrhages from the tip of
the tongue and from the tip of her right lit-
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
tie finger. She had reddish “spots” on her
face, tongue, soft and hard palate, nose, con-
junctiva, auricles, cheeks and hands, for
many years. Her mother died of frequent and
almost uncontrollable nasal hemorrhages. The
coagulation time was 5 minutes, bleeding time
2y2 minutes.
Curschmann, (April 1930), of the Medical
Clinic of Rostock, reports 2 families with
familial epistaxis as an expression of “pseudo-
hemophilia ’. He overlooked, entirely, the ex-
tensive literature now available on the subject
of familial epistaxis and hereditary telangiec-
tasia— (“Rendu-Osler- Weber Disease”). Be-
cause of the free nosebleed in all these cases,
Curschmann calls it “monosymptomatic bleed-
ing without thrombopenia and without hemo-
philia”. He advises the use of Roentgen ray
therapy over the spleen.
Kozach, of Hamburg, discussing Cursch-
mann s paper before the Northwestern Ger-
man Association for Internal Medicine at
Hamburg- Eppendorg, January 31, 1930, men-
tioned a family suffering from epistaxis.
Thomson and Mason Lamb, (1928) of
Birmingham, England, reported a case of an
unmarried woman of 30 years who had severe
bleeding from the mouth during the night,
lasting 9 hr. continuously; blood “ran in a
stream out of her mouth”. Since the age of
12 years she had severe bleeding from the
nose, and also bled from the ear, scalp and
lip. Her father, paternal grandfather and 1
of the father’s cousins were similarly affected;
1 of the father’s brothers died at 14 months,
following hemorrhage after operation (in 1876
or 1877). The patient’s coagulation time was
1 minute and 30 seconds. The blood-calcium
and cell fragility were normal. Blood Wasser-
mann was negative. They discuss Sir Thomas
Lewis’ theories and explanations for the de-
velopment of telangiectases.
Williams (1926) reports instances of hered-
itary hemorrhagic telangiectasia with nose-
bleed in 4 families. He believes that the dis-
ease is “exceedingly common”. While, perhaps,
many cases go undiagnosed, I do not believe
that the familial hereditary type of this con-
dition is so very common. I agree with Will-
iams that the hereditary character of this con-
dition is necessary for a correct diagnosis and
it is precisely this feature which is sometimes
difficult to establish. Further, that the essen-
tials of the disease entity described here are
as follows: (1) The occurrence of nosebleed
in childhood, often recurring throughout the
life of the patient, and sometimes associated
with bleeding from other mucous membranes
— stomach, bowel, bronchi, gums, and even
from the skin, lips, ears, fingers, conjunctiva,
tongue, and meninges. The bleeding may de-
crease, but very often becomes more serious
and may even prove fatal as the patient grows
older. The mother of 1 of my patients died as
the result of a severe nasal hemorrhage.
(2) The development of telangiectases, some-
times as dilated capillaries , or as arborescent,
distended venules, or as small pinkish or
dark red spots, smooth and uniform with-
out visible venules which disappear completely
on pressure often only pin-point in size. They
may appear suddenly and last for several years
and then disappear. Small nodular forms
raised, and of bright red or purplish color
may be met with. lliese were formerly
thought to be associated with malignancy of
the stomach and liver. We also meet with
spider forms (naevus araneus type), often
seen on the cheeks and eyelids of children
and young patients. The mat form being
large lesions, sometimes seen associated with
cirrhosis of the liver and leukemia, and lastly
the generalized forms of telangiectases noted
by Osier and so thoroughly discussed in one
of the best papers on the subject by Becker,
of Chicago (1926). In my paper I am dis-
cussing only the multiple hereditary forms of
telangiectases associated with recurring hemor-
rhages, and present in several or many mem-
bers of the family and in several generations.
(3) The occurrence of these symptoms in
several members of the family is essential for
the diagnosis. We may have, however, in
some members of the family, hemorrhages
from the nose alone or from other parts of
the body, with or without hemorrhagic hered-
itary multiple telangiectasia.
1 ime will not permit the review of many
interesting cases of this clinical entity. I will
simply list the typical and atypical cases re-
ported in the entire medical literature of the
world since 1830.
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NF.W JERSEY
317
Typical cases of hereditary hemorrhagic
telangiectasia with recurring epistaxis and
other hemorrhages: Wilson (1869), Legg
(1876), Chiari (1887), Chauffard (1896),
Rendu (Oct. 23 and Nov. 24, 1896), Osier
(1901), Josserand (1902), R. H. Kennan
(April 30, 1902), Kelly, A. B. (1906), Coe
(1906), Hawthorne (Jan. 13, 1906), Osier
(1907), Weber, F. P. (1907), Gottheil
(1907), Kofler (1908), Ballantyne (1908),
Semon (Jan. 10, 1908), Waggett (1908),
Phillips (1908), Hanes (March 1909), Lang-
mead (1909 and March 1910), Laffont (Oct.
Dr. Goldstein — Telangiectasia.
Osier’s Paper: Quarterly Journal of Medicine, 1907.
30, 1909), Audry (Jan. 1911, and 1920),
Osier (1911, mentioned by Steiner 1917),
. Van Wagenen (1912), Sequeira (1912-1913),
Gjessing, E. (1916), Hutchison and Oliver
(Jan. 1916), H. B. Richardson (1917),
Steiner, W. R. (1917), Paul, S. N. (1918),
Gundrum (March 1919), Goldstein, H. I.
(1921), Freudenthal, W. (1921), Goldstein,
H. I. (1922), Fitz-Hugh (Dec. 1923),
Schwarz (1925), Gulland, G. L. (May 19,
1923), East (Oct. 12, 1923 and Feb. 13,
1926) , A. Arrak (June 1925), Emile- Weil
(June 25, 1926), Williams (1926), Mekie
(March 5, 1927), McKinstry (May 1927),
Archer (Sept. 17, 1927), Balph (Dec. 22,
1927) , Mackay and McKenty (1927), Thom-
son and Mason Lamb (1928), Van Gilse and
Postma (1928 and 1929), Roles (1928), Flan-
din and Soulie (Jan. 2, 1929), Erdheim (Feb.
1929), Harper (April 1929), Rudolph Schoen
(1930), Boston (March 1930), and Cursch-
mann (Apr. 12, 1930).
Cases of familial epistaxis. Sutton (1864),
Babington (Sept. 1865), Frohlich (1891),
Verneuil (1894), Rosenberg (1900), Lane
(1916), Blumenfeld (1926), Giffin (1927),
Goldstein, H. I. (1930).
Atypical cases of (familial) epistaxis or
hereditary telangiectasia. Taunton (1830),
Tweedie (1841), Sutton (1864), Babington
(1865), Tanturri (Aug. 1879), Vidal (1880),
Frohlich (1891), Gaston (Feb. 8, 1894), Ver-
neuil (May 29, 1894), Ullmann (1896), Ivopp
(1897), F. J. Smith (1898), Blaschko (1899),
Du Castel and Baudouin (1899), Kalischer
(1901), Joseph (1904), Armand (1905),
Weber (1°07) mentions a case reported Dec.
12, 1900, before the Dermatologic Society of
London, with familial multiple venous angio-
mata; W. Bligh (Feb. 23, 1907), Adamson
(1907), Passini (1907), Pollitzer, Mayou
(1907-1908), Lack (1908-09), Fox (1908),
Hyde (1908), Steiner and Voerner (1909),
Galloway (1910), Frick (1912), Stokes
(1915), Lane (1916), Miescher (1919), Mil-
ler (May (1923), Blumenfeld (1926), S. W.
Becker (1926), Giffin (1927); (Becker," Sept.
1927), Weber, F. P. (Sept. 24, 1927), Mem-
mesheimer (1928), H. I. Goldstein (1930),
Kozach (1930) ;
Terrien and Prelat (“Telangiectasie gener-
alised et cataracte congenitale”, Nov. 6, 1909)
and M. Vulpian report patients dying from
epistaxis and hemoptysis under the title
“Hemophile — Pas d’ antecedents cl' heredite
ou de famille” (Feb. 1886).
Familial hemorrhages, hemoptysis, hema-
turia, hematemesis, bowel and rectal bleeding,
and other atypical cases — (non-hemophiliac
and non-purpuric). Atlee (1901), Guthrie
(1902), Pearson (1904), Bennecke (1906),
MacCallum (1906), Thomson (Belfast),
Ohkubo (1907), Grandidier, Kausch, Apert
(1907), Aitken (1909), Adler (June 1909),
Mantchik (1922), Libman and Ottenberg
(1923), Hurst (1923), Barford (1926), Fog-
gie (1928), Virgil Schwartz (1925), and
others.
Miescher (1919) reports a case of telan-
318
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
giectasia in a woman, aged 71 years, whose
mother died at 80 years from epistaxis. Her
31 years old daughter is well. She had telan-
giectases and tortuous capillaries on the nose,
cheeks, forehead and legs. Blood Wasser-
mann was positive. He reports a second simi-
lar case. He was able to find 19 similar cases
since Brocq’s compilation. He fails to men-
tion epistaxis or other hemorrhages in his 2
cases.
Steiner and Voerner (Deutsch. Arch. f.
klin. Med. 1909, Bd. 94, 105) speak of “angi-
omatosis miliaris” and report several cases.
They report a young man aged 29 years, with
general symmetric telangiectases — pin-point to
pin-head in size, on the chest, abdomen, geni-
talia, arms and lips. He had pollakuiria, quick
pulse, neuralgias, and anidrosis.
Francis C. Roles (November 1928, pp. 19
and 20, St. Bartholomew’s Hospital Tournal,
V°l. XXXVI, 1928-1929, London), reports
a case of multiple telangiectasis with spleno-
megaly in a married woman aged 65 years, a
machinist, suffering from “abdominal pain
and indigestion”. She had red “spots” on the
face and hands, nose, lips, tongue, cheeks, and
legs, which appeared to “come out” singly or
m crops. Three years ago she had a thrombo-
sis in the right calf and cirrhosis of the liver.
A large telangiectasis on one of her fingers
bled profusely; there was no hematuria but
increased frequency of micturition. She had
severe epistaxis. No family history of epi-
staxis or of “spots ’. She had lesions of 3
types: pin-point, spider form (most com-
mon), and the nodular variety. Three of the
nodular type on a finger, each side of nose,
and on left cheek bled quite profusely. The
spleen formed a firm, well-defined tumor the
size of an orange and showed a well-marked
notch. It was not tender. The coagulation
time was 2 minutes, 27 seconds ; and the bleed-
ing time, 2 minutes, 36 seconds.
Gastou, P. (Feb. 8, 1894) speaks of “con-
genital and hereditary vasomotor telangiec-
tases” and reports the cases of a father and
daughter. The father, daughter, and paternal
ancestors, all had red hair and a very high fac-
ial color. Both father and daughter had gen-
eralized telangiectasia. When 23 years of age
the father had a “stroke” with left sided hemi-
plegia which almost entirely disappeared in 2
months. The daughter had vascular dilata-
tions on the hands, and after a confinement
the telangiectases showed a tendency to
spread. He concludes that these cutaneous
vascular dilatations may be the result of a
vasomotor paralysis through congenital, he-
reditary or acquired modifications of the vas-
cular vasomotor centers, and he therefore des-
ignates the condition as “generalized vasomo-
tor telangiectases”. He fails to mention epi-
staxis or other hemorrhages.
Romme (Presse Med. Paris, Apr. 24, 1909)
reviews the literature and discusses hemophilia
and hereditary hemorrhagic telangiectasia but
does not report any cases of his own.
E. Gjessing (1916) reports 3 cases. One
of his patients, a man aged 30 years (whose
father and sister were similarly affected), bled
profusely from the nose when a child. Nose-
bleed became more severe as he grew older.
He had bled from the mouth on one occasion.
He suffered from heart disease, severe an-
emia, and from retinitis hemorrhagica.
Coschwitz (1616) mentions that frequent
scratching with the finger-nail at the anterior
part of the septum may be responsible for epi-
staxis.
Valsalva knew that the most frequent source
of nosebleed was a site on the anterior por-
tion of the cartilaginous septum. This site
of predilection for nosebleed was later de-
scribed by Michel, Little, Hartmann, Kiessel-
bach, Zuckerkandl, Hajek and others.
Rendu (Semaine Med. IV, June 12 and 26,
1884) emphasized the interesting fact that
epistaxis in a young patient (with or without
valvular disease) is often a premonitory symp-
tom of an attack of rheumatism, particularly
in girls, when not occurring as vicarious men-
struation.
Verneuil (May 29, 1894) speaks of “Juven-
ile, Hereditary and Heredo-Hepatic Epi-
staxis and reports illustrate familial cases. He
speaks of familial and hereditary epistaxis as
a reality. Forgues and Besnier say this form
of hereditary epistaxis in children and ad-
olescents occurs in families predisposed to
spontaneous hemorrhage and which is often
mistaken for hemophilia.
Curtius (Nov. 1928) speaks of nasal septum
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
319
varicosities and Osier’s disease as a manifes-
tation of general hereditary dysplasia of the
venous wall or a “status varicosus”.
Du Castel and Baudouin (1899) report a
case of hereditary telangiectasia in a man aged
25 years. Other members of his family had
the same condition. No mention is made,
however, of familial nosebleed.
Becker (Sept. 1927) in his paper on “Gen-
eralized Telangiectasia” reports (Case 2.) the
case of a girl aged 29 years, complaining of
changes in the skin and nails. One sister and
Dr. Goldstein — “Telangiectasia” case of Prof.
Schoen, Leipzig.
Prof. Schoen (Leipzig) Deutsch Archiv. f. Inn.
Med., 1930
2 brothers were subject to frequent nosebleeds,
and her father also had nosebleed occasionally.
She had nosebleed when in a warm climate,
generally at the time of the menses. She had
bilateral coronary cataract ; apparently no
telangiectatic lesions of the mucous mem-
branes. Her finger nails were abnormal, and
she had marked follicular hyperkeratosis.
Marked erythema of her cheeks and chin and
dilated vessels were noted.
Flandin and Soulie (Jan. 2, 1929) reported
a woman 54 years old affected with hereditary
hemorrhagic angiomatosis. She suffered from
profuse epistaxis and had carmin-red vascular
spots on the cheeks, chin, tongue and fingers.
She had an intense anemia. The bleeding and
coagulation time was normal and the clots were
retractile.
Mekie’s (March 3, 1927) patient was a man
aged 38 years who had numerous telangiectases
on the lips, nose, cheeks, tongue, nasal septum,
gums, soft palate and penis. He suffered
from frequently recurring nosebleed and ad-
vanced pulmonary tuberculosis. His father,
grandfather, 2 uncles, sister and 3 cousins were
similarly affected. His 7 children, under 15-
years, were apparently not affected. One of
the affected cousins died at the age of 28-
years from a “ruptured vessel in the brain”.
Kofler, (Karl, 1908) reported a man aged
50 years who had repeated hemorrhages from
the nose and lips. He had “spots” (telangiec-
tases) on the face, lips, nose, nasal septum,
mouth, ears, scalp, extremities and trunk. His
mother and brother were similarly affected.
His children were apparently not affected.
Kofler erroneously reports this case as
“Naevus Pringle of the Skin” and while he
knew of Osier’s and Parkes- Weber’s cases, he
did not think they were the same. I consider
this a typical example of hereditary telan-
giectasia with epistaxis (familial).
Van Gilse and Postma (1928) of the Uni-
versity of Amsterdam, report 4 cases ("from 2
Dutch families) all suffering from severe
persistent nasal hemorrhages as a symptom of
congenital telangiectases of the skin and
mucous membranes.
Audry (Jan. 1911) reports the case of a
man aged 70 years who for many years had
almost daily nosebleed. He had telangiectases
on his face, lips, palate, tongue, trunk and
arms. His mother, great aunt, cousin, niece,
maternal uncle, 5 brothers and sisters, 2 sons
and several nephews were all similarly af-
fected. He considers Chauffard’s (1896) a
non-familial (atypical) case.
Langmead’s (March 1910) patient was a
man aged 68 years. He had 30 small tel-
angiectases, and frequent nosebleed; occasion-
ally the face or tongue would also bleed.
320
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
Secondary anemia was present in 1907. In
1909 the blood count was normal and he was
considerably improved. Four brothers, 1
sister, his father, and 2 sons, and a daughter
of 1 of his brothers, were similarly affected.
The patient’s mother suffered from severe
epistaxis.
Erdheim (Feb. 1929) was able to collect
from the literature 55 families with this dis-
ease. He reports 6 persons (who are now
alive) in 1 family, who have frequent attacks
of epistaxis with no serious consequences. He
also gives reports of 5 persons deceased, 2 of
whom probably died as the result of the
severe repeated hemorrhages. He is con-
vinced from his studies of 49 cases that the
telangiectatic lesions were first noticed in 31
cases under the age of 30, and in the other 18
past the age of 30. The lesions seem to be-
come aggravated in many patients in later
life.
Fatal hemorrhages in some of these cases
were reported by Kelly, Legg, Chiari, Phil-
lips, Gottheil, and others.
Paul ( 1918) reported the first Australian
cases. He reported a woman aged 32 with
hereditary angiomas and epistaxis. He traced
the disease as far back as the great-grand-
mother and both her daughters, and grand-
mother of Paul’s patient; 21 members of this
family were affected.
Archer (Sept. 17, 1927) reported a case
of multiple cavernous angiomas (“of the
sweat ducts”) associated with hemiplegia in
a man aged 30 years. One brother shows the
same telangiectatic lesions. Parents are alive
and well. Patient suffered from frequent at-
tacks of bilateral frontal headache. In 1918
he developed a right hemiplegia (at 21 years
of age). The attack came on suddenly
during the day. Complete recovery took place
in 2 years. In 1922, he had a similar attack
in addition to involvement of the left side
of the face with loss of speech. There was no
loss of consciousness in either attack. He re-
covered completely from the last attack, ex-
cept for pain in the extremities and back. The
patient seems mentally dull. Pie always feels
“cold”. The optical discs show a varicose and
degenerated condition of the retinal vessels,
but not hemorrhages. The skin shows multi-
ple small pinhead disseminated angiomas dis-
tributed over the lower thorax, abdomen, sides
of trunk, buttocks, thighs and genitalia. The
mucous membranes of the lips, cheeks, and
soft palate were also involved, but not the
tongue. Spinal fluid and blood Wassermann
tests were weakly positive. No reports of the
blood platelets, blood chemistry, basal meta-
bolism, radiograph of the sinuses, skull and
teeth are included. No hemorrhages from the
nose or mouth are mentioned. Archer con-
sidered the hemiplegia due to bleeding from a
similar (angiomatous) varicose and degener-
ated condition of the vessels in the brain. He
mentions, further, that such mental sluggish-
ness is a frequent symptom in lichen planus,
adenoma sebaceum and hypothyroidism.
McKinstry’s patient (May 1927) was a
girl aged 19 years, with advanced bilateral
pulmonary tuberculosis. She bled from the
nose and had 5 or 6 punctate subcutaneous
hemorrhagic spots on the tips of her fingers,
and “spider webs” (telangiectatic) in the an-
terior part of the nasal septum. Her father
was a “bleeder”.
Laffont (Oct. 1909) mentions the observa-
tions by Kopp, Chauffard, Rendu, Steiner-
Voerner, Blaschko, Joseph, and Hanes, and
reports his own cases. He divides the cases
into hemorrhagic and non-hemorrhagic types.
Hart-Drant (May 14, 1923) reported an
atypical case of acquired multiple punctate
telangiectases of 7 years’ duration in a white
woman aged 40. Epistaxis is not mentioned.
I shall not review in this paper the interest-
ing cases reported by Guthrie (1902), Aitken
(1909), Legg (1876), Hutchinson and Oliver
(1916), Gundrum (1919), Osier (1901, 1907,
1911), Hanes (1909), Steiner (1917), F.
Parkes- Weber (1907), Fitz-Hugh (1923),
East (1926), Griffin (1927), Balph (1927),
L. N. Boston (1930), Van Gilse and Postma
(1928, 1929), and others.
Recently (January 1930) there was a pa-
tient (Max G. 1930-15) in the service of
Professor Alfred Stengel, University of
Pennsylvania Hospital, who died as the result
of persistent severe hemorrhages, shock from
repeated large blood transfusions, toxic hepa-
titis, and cholemic nephrosis. The man was
64 years old. For many years he had severe
April, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
321
recurrent attacks of nosebleed, and many
telangiectatic lesions in the nose, roof of
mouth, trachea, left bronchus, and rectum. In
September 1927 he had “black stools”, and in
Tune 1929 he had very profuse nosebleed, re-
quiring blood transfusion. Bleeding and
clotting time and blood-platelets were normal.
He had an enlarged spleen.. At necropsy the
spleen was found to weigh 660 gm. Size
19x3x7 cm. ; slate gray in color ; areas of
hemorrhage were noted. No gross evidence
of telangiectases was found in the stomach
and intestines. Seven other members . of his
family including 1 brother, 2 sisters, 1 son, 3
daughters and his mother, all bled from the
nose.
Dr. Goldstein — Telangiectasia.
Osier’s Paper: Quarterly Jour, of Med., 1907.
Treatment
As the condition is due to some hereditary
defect of the vascular system, little can be
•done. • For the local bleeding, the chromic acid
bead, electric cautery, carbon dioxide snow,
astringents and radium have been tried. Ad-
ministration of calcium by mouth and intra-
venously, parathormone injections, viosterol ;
ultraviolet ray and x-ray therapy, liver, liver-
fraction, iron, arsenic, and endocrin therapy
have given varying results. In severe hemor-
rhages, whole-blood injections, blood serum,
blood-transfusion, coagulen, stryphnon (Mey-
er and Albrecht), thromboplastin, afenil and
calcium gluconate may be useful.
Professor B. Niekau (Tubingen) and Pro-
fessor F. Llopis (Madrid) recommend the
use of Nateina Llopise, a mixture of vitamins
A, B, C and D, of vegetable origin, to which
calcium phosphate and lactose have been add-
ed. Five tablets are chewed before meals.
This is considered a good remedy in hemo-
philia.
Taylor (July 1929) has apparently cured
purpura hemorrhagica by the use of bothropic
antivbnin.
Rendu suggests cold compresses to the head
and neck, lifting the arms, decoction of walnut
leaves, or a little alum, tamponing when neces-
sary, and the administration of opium. Gubler
believes opium is the best remedy in some cases
when epistaxis is excited by excessive nerve
stimulus.
Pagueguy (Paris, 1831) recommends the
introduction of a piece of hog’s intestine pre-
pared in the form of the finger of a glove
and this can be filled with fluid by means of
a syringe after which a ligature is applied to
prevent escape of the fluid. Thus, the
mucous membrane of the nose is compressed
and the hemorrhage arrested. Wicks of lint
moistened with alum solution were used for
tamponing. He used wine of quinin and iron
as tonics.
G jessing uses calcium lactate regularly and
as a prophylactic remedy.
Osier used calcium chloride.
Emile- Weil suggests using carbon-dioxide
snow ( June 1926) and has obtained some good
results.
Leeches applied to the back of the neck and
to the buttock was advised by Scharin, of
Russia.
Compression of the nose with thumb and
index finger is at times a useful procedure.
Stenger (1915) in his thesis for the University
of Wurzburg, discusses, most thoroughly, the
various forms of treatment for nasal hemor-
rhages. He suggests the use of cauterization
with chromic acid crystals or silver nitrate for
the telangiectases, followed by loose tampon-
age with 10% bismuth ointment. He has also
tried styptol, secacornin, coagulen and the
gelatins.
McBride (University *of Penna. Med. Mag.
II, 1889-1890, pp. 424-426) reports 2 fatal
cases of nosebleed and 1 case that was nearly
fatal ; the last patient, a law student, aged 17,
who bled for many days. D. Hayes Agnew
322
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 19 31
suggested 2 cylinders of bacon so as to tightly
plug the nostrils. This stopped the bleeding
for awhile. Later, McBride used a cylinder
of ham fat which “acted like a charm”. Ed-
ward Martin and the late J. William White, of
the University of Pennsylvania, also saw this
patient. In the hypertensive, arteriosclerotic
cases angioxyl may he given by injections and
by mouth, and also iodides.
Conclusions
(1) A review of the literature of the world
on the subject of familial epistaxis and hered-
itary telangiectasia is here briefly discussed.
(2) There are probably a total of 65 fam-
ilies and about 3oO individuals suffering with
this clinical entity— “hereditary (familial)
epistaxis with multiple hemorrhagic hereditary
telangiectasia” — on record in the entire avail-
able medical literature of the world.
(3 ) Many cases, no doubt, have been over-
looked bv the otolaryngologists, dermatolo-
gists, and pediatricians. A more careful
study of cases of epistaxis and of those com-
plaining of various forms of telangiectases and
angiomatous lesions of the skin and mucous
membranes will bring to light additional cases
of this disease entity.
(4) Cases of familial hematuria, hemor-
rhagic nephritis, hemoptysis, “gastrostaxis”,
intestinal and gastric bleeding, and some of
the so-called essential idiopathic hemorrhages,
are probably different forms of this disease.
(5) Reports of cases of familial epistaxis,
with and without skin and mucous membrane
(vascitlar) lesions, are included in this paper.
During the past 21 years I have met with
3 families in whom epistaxis occurred repeat-
edly and profusely. The first family (W.)
\\ as a typical instance of multiple hemorrhagic
hereditary telangiectasia with familial epi-
staxis; 11 members of this family, were so af-
fected. This family was reported by me in
1921 (Arch. Int. Med.).
Recently one of the patients was treated
in the Atlantic City Hospital. In 1918, at the
age of 42, she had a ’‘stroke”, due to bleeding
from a cerebral telangiectatic lesion. Blood
Wassermann test was negative. Renal func-
tion tests, blood chemistry, blood platelets,
coagulation and bleeding time, and blood pres-
sure, at that time, were normal. There was
no evidence of embolism, hemophilia, purpura,
arteriosclerosis, hypertension, endarteritis ob-
literans, syphilis, uremia, or vascular crises.
During her recent stay (April 1930) in the
Atlantic City Hospital, in the service of Dr.
Barbash, her condition was very poor, and
blood transfusion was necessary. Laboratory
studies, made at the hospital, showed as fol-
lows: April 3, 1930, R. B. C., 1,410,000; W.
B. C., 12.750; hemoglobin, 35%; color index,
1.2 plus; polys., 89%; s. lym., 9%; 1. lym.,
1%; baso., 1%. Large amount anisocytosis,
macrocytes predominate; slight poildlocytosis ;
marked achromia and polychromasia.
April 7, 1930, after transfusion, R. B. C.,
1,910,000; W. B. C., 22,750; hemoglobin,
35%; color index, 0.9 plus; polys., 85%; s.
lym., 13%; baso., 1%; mono., 1%. Slight
poikilocytosis ; marked anisocytosis; macro-
cytes predominate ; marked achromia and
polychromasia; occasional nucleated red cell.
Apiil 15, 1930, W. B. C., 12,500; hemo-
globin, 30%; color index, 0.7 plus; R. B. C.,
1,690,000.
April 16, 1930, R. B. C., 2,010,000; W. B.
C. , 8,300 ; hemoglobin, 20% ; color index
0.5.
April 7, 1930, reticulocyte count 1.2%;
\\ assermann and Kahn negative. Coagulation
tune, 5 minutes; icterus index, 2.
April 15, 1930, platelet count, 66,000. April
16, 1930, percentage of banded W. B. C.,
16/o , blood calcium, 8.4 mgm. % ; fragility
test, minimal hemolysis, 0.40% ; maximal,
0.34%.
Report of Author's Cases
First Family (1918-1921)
Case 7. Mrs. R. W., aged 42 years, white,
married, has had severe persistent and recur-
ring attacks of epistaxis since childhood. She
has 2 daughters and 2 sons. One daughter,
aged 20 years, has bled from early childhood.
The other daughter, aged 11 years, has bled
from the nose nearly all her life. The pa-
tient has telangiectatic lesions on the nose,
nasal septum, lips, tongue, chin and cheek.
There are a few lesions on the left side of
the neck, and 1 on the middle finger of the
left hand. None are seen on the thighs and
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
323
legs. The larger spots on the tip of the
tongue have bled on several occasions. Bleed-
ing from lower lip occurred once. Sometimes
the hemorrhages from the nose are very pro-
fuse and uncontrollable. The patient received
ferrous carbonate, sodium arsenate, calcium
lactate -and calcium chloride at various times.
She also used thyroid and lutein for a brief
period. Secondary anemia is present. Her eld-
est daughter has a few spots on the tongue, 1
over the right clavicle and some on the fore-
arms. The younger daughter has none on the
lace or body, and only 2 very small ones are
seen on the tongue. The patient’s mother,
Dr. Goldstein — Telangiectasia.
Osier’s Paper: Quarterly Journal of Medicine, 1907.
who is dead, also had recurring attacks of
epistaxis and red spots. Three sisters are mar-
ried ; 2 have nosebleed ; 1 sister, 34 years of
age, bleeds profusely from the nose.
Her 4 children, J. H„ 13 ; A. H„ 11 ; M. H„
6, and I. H., 3; all suffer from epistaxis. An-
other sister, A. L., aged 32, bleeds from the
nose. Her son, M. L., aged 8, does not bleed.
A third sister, Mrs. M. C., aged 30, and 2
children, J. C., aged 10 and E. C., aged 5,
apparently do not bleed.
Mrs. R. W. (the oldest daughter) had a
“stroke” and hemiplegia January 20, 1918,
after a little giddy spell. This attack was due
to defects in the small vessels, like those oc-
curring in other parts of the body, or a peri-
pheral sclerosis. Blood Wassermann tests
were negative on several occasions. Blood
chemical tests showed urea nitrogen 18 mg. in
100 c.c. blood ; nonprotein nitrogen, 35 mg. ;
creatinin, 2.20 mg.
Urine. Jan. 26, 1918, trace of albumin;
sugar less than 0.1% ; chlorides, 0.5% ; specific
gravity, 1.005; granular and hyalin casts;
flat, round and caudate epithelial cells; urea,
1% ; acid.
March 11, 1919: Albumin present; urea,
0.5%; amorphous urates present; total solids,
16.3 gm. ; faintly acid; specific gravity, 1.009;
no casts ; no sugar.
July 24. Acid; specific gravity, 1.015: no
acetone; no diacetic acid; slight excess of in-
dican 1 5 times normal ; urea, 0.6% ; no diazo
reaction ; slight excess of urorosein ; no casts
and no cylindroids ; many red blood cells ;
many renal epithelial cells ; large number of
leukocytes (pus) ; 35 oz. urine voided in 12
hours.
Eyes: April 30, 1919. Posterior polar catar-
acts in both eyes.
Blood : Coagulation and bleeding time nor-
mal. Feb. 15, 1918. Erythrocytes, 3,980,000;
leukocytes, 12,600; hemoglobin, 61%. Differ-
ential count : polymorphonuclears. 64% ;
transitionals, 2% ; eosinophils, 3% ; mast cells,
1%. July 24, 1919. Erythrocytes, 300,000;
leukocytes, 14,600 ; hemoglobin, 68% ; poly-
morphonuclears, 60% ; large mononuclears,
12% ; small mononuclears, 24% ; transitionals,
2%; eosinophils, 2%.
The phenolsulphonephthalein renal function
test was practically normal. The blood pres-
sure varied during the past 3 years between
128 systolic and 90 diastolic, and 110 systolic
and 80 diastolic.
Comment. At the time she had the stroke
it was difficult to decide as to the cause. One
could not easily differentiate between em-
bolism, thrombosis and hemorrhage. There
was no evident source of an embolus. A faint
murmur could be heard over the heart, and
at times it was faintly audible at the apex,
but it could be attributed to the anemia.
Shortly after the cerebral hemorrhage, the
systolic blood pressure was 140; however, at
no time during the past 3 years has it been
higher than the normal average, often below.
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
She complained of a heavy feeling and numb-
ness in the limbs, and “heaviness with giddy
or dizzy feeling in the head”. She had crying
spells occasionally, worrying over her condi-
tion. She was seen by Dr. O. H. Perry Pep-
per at my request, who reported also that her
dotting and bleeding time was normal.
There is no history of hemophilia in the
family and none of the family bleed exces-
sively from cuts. One son, A. W., aged 12
years, has several small telangiectases, and a
large pale reddish nevus on the back of the
left shoulder and 1 telangiectatic lesion be-
low the right lower eyelid. He does not bleed
from the nose. The eldest son, L. W.. aged
23 years, apparently has neither epistaxis nor
many telangiectases. There are a few over
the scapular regions (supraspinous), and 1
lesion about 4 in. below and to the left of the
left nipple.
At the time of the “stroke”, and since, the
patient, Mrs. R. W., has been seen by A. E.
Roussel, F. X. Dercum, Charles Potts, W. G.
Spiller, A. Gordon, of Philadelphia; T. D.
Taggart, of Atlantic City; S S. Butler, of
Camden, and others, during the past 3 years;
however, none of them made the diagnosis of
hereditary telangiectasia with recurring hemor-
rhages, and did not associate the nosebleed
and the cerebral complications with the hered-
itary weakness of the vascular system. Dr.
Pepper agreed with me in my diagnosis.
Case 2. Mrs. Anna L., aged 32 years; mar-
ried 7 years, had one miscarriage at 6 months,
and 1 premature birth at 8 months, the child
living only 24 hours. Her husband had a
positive Wassermann test. The patient had a
positive Wassermann 9 years ago. She has
1 boy, M. L., aged 7 years, living and well,
who does not bleed from the nose. The pa-
tient has had nosebleed since early childhood;
very frequent; bleeding stops of itself. Had
influenza and pneumonia and measles. She
bleeds very profusely from the left nostril.
Her hands are cold, and she gets short of
breath on exertion. Occasionally, she bleeds
from hemorrhoids. She has 7 or 8 small
spots over the back, on the shoulders, 2 small
spots back of ears, several on the left side
(anteriorly) of septum of nose and 1 or 2
on right side of septum. There are a few
radiating dilated capillaries around the alae of
the nose. She also has clubbed fingers; these
are cyanosed and cold; the lips are cyanosed
and get “blue” very often. Blood pressure:
systolic, 95 ; diastolic, 70. No cardiac mur-
murs were heard at time of the examination
but the heart sounds were not of good quality;
they were weak and muffled. She is a sister
to the above patient (Case 1) Mrs. R. W.,
and to Mrs. E. H. (Case 3). Numerous Was-
sermann tests have been negative, following
specific treatment taken up to a few years
ago.
Case 2. Mrs. Eliz. H., aged 35 years, has
4 children. She had 1 miscarriage. One in-
fant, aged 1 month, died of whooping-cough.
She was operated on 4 years ago for ruptured
gastric ulcer with intestinal obstruction. She
has been bleeding from the nose almost daily
since childhood. She says her mother bled
“terribly” from the nose for a great many
years, and she thinks her death was due to
these severe nasal hemorrhages. She has a
pin-point lesion above the right eyebrow, 3 or
4 spots on the right cheek over the malar
hone, 1 pin-point lesion on the left cheek 1 in.
to left of the outer angle of the left eye; 3
or 4 lesions on right half of the lower lip;
1 spot on the under surface of the upper lip;
1 on upper gum; 1 spot on neck at base (right
side). She gets attacks of nosebleeding even
during her sleep.
Case 4. Marvin H., aged 5 years, was al-
ways well, except for severe nasal hemor-
rhages. He has had nosebleed daily, and dur-
ing sleep, since 2 years of age. He has 1 spot
on left cheek, 1 in. below outer angle of left
eye, and 1 on right cheek, 1 in. below and in
front of right ear. Several dilated capillaries
are noted on right side of septum of nose. He
had measles. Mother says boy “bleeds in
streams from nose” daily, which stops itself
after bleeding for 5 or 6 minutes. While the
hemorrhages have been severe and prolonged;
there is only a comparatively mild secondary
anemia. Sometimes washing the face, or us-
ing a handkerchief, or other very slight trauma
is sufficient to bring on an attack of epistaxis.
Blood examination, Oct. 11, 1920: Hemo-
globin, 70%; erythrocytes, 2,900,000; leuko-
cytes, 8000; polymorphonuclears, 51%; small
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
325
lymphocytes, 45% ; large mononuclears, 3% ;
eosinophils, 1%. Marked poikilocytosis.
Blood Wassermann negative.
Cases 5 and 6. Aaron H., aged 11 years,
and Jeannette H., aged 13 years, the children
of E. H., have bled very profusely from the
nose since 2 years of age. They have “spots”.
Blood examination, Oct. 11, 1920. Jean-
nette: Hemoglobin, 75%; erythrocytes, 3,-
350,000 ; leukocytes, 7400 ; polymorphonu-
clears, 72% ; small mononuclears, 25% ; large
mononuclears, 2%i; eosinophils, 1%. Some
anisocytosis and poikilocytosis. Blood Wasser-
mann negative. Aaron : Hemoglobin, 80% ;
erythrocytes, 3,250,000; leukocytes, 11,000;
polymorphonuclears, 61% ; small mononu-
clears, 36%; large mononuclears, 2%,; eosin-
ophils, 1%. Some poikilocytosis and anisocy-
tosis. Blood Wassermann negative.
Boggs
Test Tube
Marvin H.
5 min.
6 min.
Jeanette H.
6 min.
7 min.
Aaron H.
5 min.
4 min.
Second Family (1922)
(1) Mr. C., aged 33 years, white, adult,
male. Autoparts mechanist. Past history
negative, except that he has had frequent at-
tacks of nose bleed for many years. In the
past 3 or 4 years he has been complaining of
severe headaches, particularly a left hemi-
crania. He is married, has 4 children, 2 boys
and 2 girls. His wife has not had any mis-
carriages. Venereal disease denied. One son
and 1 daughter have had repeated attacks of
nosebleed a number of years. General ex-
amination negative. The x-ray findings are as
follows : Peri-apical abscess at the root of
the last upper left molar; should be extracted.
An incipient abscess at the root of the last
lower left molar; this tooth, I believe, can be
saved by early treatment. Sinuses : distinct
clouding of the left antrum and right frontal
due to presence of a fluid exudate or pus. The
other accessory sinuses are normal.
Nose and throat examination showed free
discharge of a mucopurulent nature from the
left nostril and a degenerated middle turbi-
nate of a colloidal character with obstruction
to free drainage from the ethmoid and
frontal sinuses. There is distinct evidence of
a frontal sinusitis and disease of the left an-
trum of Highmore.
(2) Dorothea C., aged 8 years. White girl,
daughter of the above patient. Has had
measles , chicken-pox and whooping-cough.
Enlarged tonsils and adenoids. General ex-
amination negative. Has had repeated at-
tacks of epistaxis; more often than her little
brother. On examination 37 small brownish
spots were found scattered over the trunk,
neck and legs. One small telangiectatic spot
about 2 in. below the right ear on the side of
the neck and the left ear. Numerous very
fine and dilated capillaries (arborescent and
spider-like) over both cheeks. A few dilated
capillaries are seen over the left nasal ala.
One dilated capillary visible over the sternal
end of the right clavicle and 1 over the right
shoulder. There are some visible capillaries
over the space between the left scapular spine
and vertebras.
(3) Harry C., aged 6 years. White boy,
brother to the above patient. Has had
measles, chicken-pox, grippe, and whooping-
cough. Has attacks of hemorrhage from the
nose; not very frequent of late. General ex-
amination negative. Has a pale pink nevus
on the back of the neck, 2x1 J4 in. and another
“birth-mark” over the middle of the back
1 in- He has 28 brownish spots scatter-
ed over the body, resembling dark pigmented
freckles. There is visible one area of dilated
capillaries over the left cheek.
The father had several telangiectatic lesions,
1 or 2 on the neck and 35 or 40 dark pigment-
ed spots, dark brown in color, scattered over
the neck, trunk and arms. His tonsils were
removed about 8 months ago.
Third Family (1929)
Mr. H., aged 29. Suffering from migraine
and headaches for past 15 years. Had diph-
theria. typhoid fever, pneumonia, 3 attacks of
acute articular rheumatism. Now has occas-
ional pains in the joints. Had nosebleed fre-
quently and nearly bled to death following
tonsillectomy. Is “drowsy” and “fatigued”
and cannot concentrate. Mother has diabetes.
Father and 2 brothers affected by nosebleed.
Blood Wassermann tests were negative. Urin-
326
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
alysis negative. Bleeding time, 2 J4 minutes.
Clotting time, 11 minutes (hypocalcemia).
Blood calcium, 7.9 mgm. per 100 c.c. blood.
Blood sugar, 90 mgm. per 100 c.c. blood.
Blood count: R. B. C., 4,390,000; platelets,
290,000; W. B. C., 10,000; polys., 59%; small
lymps, 39%.
Radiograph of sinuses showed clouding of
left antrum. Sella turcica, normal. Teeth
negative.
Eye examination, low amount of far-sighted
astigmatism. Basal metabolism minus 25%.
Removal of the tonsil stump, cleaning the
antrum, the administration of thyroid ex-
tract, calcium, parathormone, and ultraviolet
ray therapy brought about rapid improvement.
Blood calcium rose to 11 mgm. Blood uric
acid, 3.8 mgm. Creatinin, 1.4 mgm. Basal
metabolism became normal. One brother, aged
23 years, bled severely after tonsillectomy. An-
other brother, aged 25 years, bled profusely
after tonsillectomy (1924) ; followed by pneu-
monia. Another brother, aged 42 years, used
to bleed from the nose. His 3 sons do not
bleed. The father, aged 68 years, had severe
nosebleed when younger. One sister and 1
brother do not have nosebleed.
These instances of familial epistaxis re-
semble the type of cases reported by Giffin,
of the Mayo Clinic, in the American Journal
of Medical Sciences, 1927.
Diagnosis
The differential diagnosis must be made
from “pseudohemophilia,” hypertensive epis-
taxis, purpura hemorrhagica, hemophilia, per-
nicious anemia, tuberculosis, deficiency dis-
ease, or “hemorrhagic diathesis”. Blood plate-
lets, bleeding and clotting time are usually
normal. Men and women are affected, and
both sexes may transmit the condition.
REFERENCES
Acknowledgment is made of the privilege to
use the illustrations — by permission of Archives of
Internal Medicine (Chicago) and Quarterly Jour-
nal of Medicine (Oxford, Eng.).
1. Goldstein, H. I. Archiv. Int. Med., Jan., 1921.
2. Flandin and Soule, La Presse Medicale, Jan.
2, 1929.
3. Erdheim, S. H., Brit. Jour. Dermat. and Syph.,
Feb., 1929.
4. Van Gilse and Postma, Nederl. Tijdsch. v.
Geneesk, Vol. 72, 1928.
5. Schwartz, Minnesota Med., Aug., 1925.
6. Kofler, Wien. klin. Wchnschr., 21:570, 1908.
7. Emil-Weil, Bull, et Mem. Soc. Med. d. hop. de
Paris, 50:1135, June, 1926.
8. Meltie, Brit. Med. Jour., March 5, 1927.
9. Rendou, Gaz. d. hop. Paris, 69:1322, Nov. 24,
1896.
10. Goldstein, H. I., Jour. Med. Soc., New Jer-
sey, 19:50, 1922.
11. Gillin, Am. Journal Med. Scs., 174:690, Nov.,
1927.
12. Harper, Newcastle Med. Jour., April, 1929.
13. Schoen, Deutsch. Archiv. f. klin. Medizin,
p. 156, 1930.
14. Arrak, Deutsch. Arch. f. klin. Med., p. 287,
1925.
15. Williams, Arch. Dermat. and Syph., Julv,
1926.
16. Boston, L. N., Medical Times (N. Y.), March,
1930.
17. Fitz-Hugli, Am. Jour. Med. Scs., Dec., 1923.
18. Edel, van Gilse & Postma, Acta oto-laryng.,
13:525, 1929.
19. Becker, Acta Dermato-Venereologica, 8:117,
Sept., 1927.
20. Parkes-Weber, Brit. Jour. Childrenjs Dis.,
21:198, July-Sept., 1924.
21. Thomson and Mason Lamb, Birmingham
Med. Rev., Sept., 1928.
22. Hoffman, Medic, rational, systemat. Pars II,
Sect. I, Cap. I u Opusc. Physicomedica, p. 196,
1740.
23. Sutton, Medical Mirror (London), Pages 769-
781, 1864.
Hanes (1909) defines this clinical entity as an
hereditary affection manifesting itself in localized
dilatations of capillaries and venules, forming dis-
tinct groups or telangiectases which occur espe-
cially upon the skin of the face, nasal and buccal
mucous membranes and give rise to profuse hemor-
rhage either spontaneously or as the result of
slight trauma.
Discussion
Dr. Matthew S. Ersner (Philadelphia) : I wish
to congratulate Dr. Goldstein upon the splendid
manner in which he presented his paper. The
bibliography and analysis will remain as an ac-
cepted record for some time to come; I feel that he
has left no stone unturned for he has covered the
subject most thoroughly.
Epistaxis, commonly known as “nosebleed”, oc-
cupies an important place in the practice of rhin-
ology. The average individual who loses blood
from any source, irrespective from where it comes,
loses his general sense of proportion, becomes
frightened, and so annoys himself, his family and
the attending physician. When one stops to con-
sider that the most precious of life’s fluids is pour-
ing forth and leaves in its path a pale, asthenic,
anemic and an almost helpless individual, one real-
izes that “blood is blood” in any language and we
must deal with epistaxis from a general as well as
from a local standpoint.
Hereditary hemorrhagic telangiectasia may be
defined as an hereditary abnormality which upon
endonasal examination reveals localized dilatations
of capillaries and venules. These telangiectatic
areas can also be found in other parts of the body.
The most prominent bleeding points in the nasal
region are the Kesselbach area, middle of the sep-
tum, near the root of the turbinate and floor of
the posterior portion of the nose. The important
blood vessels that we encounter in these areas are
the internal sphenopalatine and the superior coro-
nary arteries.
Upon careful perusal of history, one will learn
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
327
that this condition occurs both in the male and
female and is hereditarily transmitted both from
the maternal and paternal sides. In some cases,
however, it is difficult to prove that heredity fol-
lows the Mendelian law.
The 3 cases which I have in mind are of heredi-
tary origin. The first, a male, was transmitted
through the mother; the second, a female, through
the father; the third case represents a close inter-
marriage of blood relations, the father having a
history of gastric bleeding and the mother of nasal
bleeding. The question of atavism, therefore,
seems positive at least from these cases which I
am about to quote.
Case 1. D. G., male, aged 6. In 1918 patient was
first examined by me for a nasal hemorrhage. His
chief complaint was profuse recurrent nasal bleed-
ing which would occur upon slightest provocation
or ■without any apparent cause. Family history
revealed that his mother and sister were the bleed-
ers in the family. As he grew older the epistaxis
of the nose became less frequent. Although, it
has been necessary for him to remain under my
care for treatment at different times.
Case 2. S. M., female, aged 20, came under my
observation in 1924 for recurrent nasal bleeding.
Endonasal examination revealed a septal spur and
dilated blood vessels. These would bleed exces-
sively at different intervals. From the family his-
tory we learned that the father had gastric hemor-
rhages. His Wassermann and blood picture
were negative. He died at the age of 40 from hemi-
plegia, probably due to a telangiectasia of the
lenticular artery. About 4 months ago I again was
called to see the patient who had another attack
of epistaxis.
Case 3. M. B., male, aged 5. From the family his-
tory we learned that the father and mother were
closely related, that the father had gastric hemor-
rhages and that an exploratory abdominal opera-
tion was performed but there was no abatement
of the symptoms. The mother gives us a history
of recurrent nasal bleeding and informed us that
at the. time of delivery she almost bled to death.
Eight days after delivery, the infant was circum-
cised, and profuse hemorrhage followed the proce-
dure. The child at the age of 5 was brought to me
for tonsillectomy and because of the history of
familial hemorrhage all precautions were taken.
The blood coagulation, bleeding time, blood plate-
lets and complete red and white count were taken
and were found to be normal. As a further pre-
caution, we administered calcium lactate by mouth
and thromboplastin and parathormone hypodermi-
cally. Irrespective of all these precautions, a severe
postoperative hemorrhage occurred which neces-
sitated a 10 day hospitalization for the child. At
the present time she is 11 years old and frequently
gets nasal hemorrhage.
Dr. Henry C. Barkhorn (Newark) : It is obvious
that Dr. Goldstein is a “professor” on this subject
and that it is hopeless for me to discuss even the
bibliography. We have all seen telangiectasia with
nosebleed. We have all seen families who said
they were familial bleeders. The important thing
to emphasize in this paper, and undoubtedly it is
in the context, is that this is not related to hemo-
philia. It is not handed down through the female,
nor are the blood changes of hemophilia present,
but it occurs with these nevi which Cushing, for in-
stance, has devoted a whole section in his book on
intracranial vascular tumors — to the coincidence of
nevi of the skin and nevi of the dura and mucous
membranes. It occurs, as the doctor says, in pro-
tein locations. We have found that in handling
these cases the best proposition perhaps was to
infiltrate with novocain under the nevus and then
to cook it with the Bovi apparatus, or some ap-
paratus, of that type, rather than to cauterize it
with the actual cautery. The cooking current takes
care of it without hemorrhagic manifestations;
with the cautery you just go from one mess into
a worse one and get more and more bleeding.
One must remember that if the bleeding comes
from the middle turbinate region it comes from
the anterior ethmoidal, which is a branch of the
internal carotid, not the external, and you have
to tie the internal carotid artery. If it comes from
the septum it is from the external carotid and
tying the external carotid will be adequate. This
is for the dangerous cases.
I think it is very gratifying for this section to
have had a real piece of research of this sort
brought to our attention and to have it published
in the Journal under the auspices of this section.
It is most unusual, it is different, it isi something
that leads us to think, and it is something I am
sure that will make all of us go into the history
of the next patient who says, “Oh, yes, I used to
bleed also”, and see if we can find any hereditary
connection and any nevi anywhere on the body.
MEDICOLEGAL ASPECTS OF DIS-
ABILITY IN INDUSTRIAL LEAD
POISONING
Max Kummel, M.D.,
Member New Jersey Bar
Newark, N. J.
The most difficult and perplexing problem
in connection with lead poisoning is the ques-
tion of prognosis and disability. A careful
search of general literature and text-books,
both old and new, fails to disclose definite
conclusions as to the amount and character of
disability following industrial lead intoxica-
tion. For this reason I include no bib-
liography and confine my conclusions solely to
actual cases that have come under, my obser-
vation and study during the last few years,
including not only those whose cases are
pending before the compensation bureau and
who suffer from an additional morbid psychic
state, but also those whose claims have been
adjudicated. It is the latter, who may gain
no further benefits by their complaints, whose
cases have been acted upon and “finally” ad-
judicated, that can serve as a criterion and, by
way of example, demonstrate what disability
and physical incapacity may result from lead
poisoning.
That lead poisoning will occur among indus-
trial workers no matter what preventive
328
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
measures are adopted or precautions taken
goes without saying. Under favorable cir-
cumstances, with most modern safeguards the
incidence of lead poisoning is greatly re-
duced and the disability in existing cases
minimized. However, there is danger of
over-confidence in safeguards. The attending
physician of a recently built storage battery
plant, with all the modern devices that safety
engineering can provide, assured me that no
cases of lead poisoning could possibly occur
in their plant. There are hoods, gloves, res-
pirators, ventilators, shower-baths and even a
change of linen. The workers are carefully
scrutinized, foreigners are generally rejected,
physical examination made at frequent inter-
vals, and even ordinary illnesses are treated by
the plant physician at the company’s expense,
in order to detect and arrest incipient cases. Yet,
aftct a comparatively short time, a great many
men were taken acutely ill and have since been
undergoing treatment for lead poisoning. The
explanation lies in the very nature of the in-
dustry and its inherent hazards.
Industrial lead poisoning is a very costly
affair. The annual wage loss attributable to
this disease amounts to millions of dollars and
the annual total loss to about 5 or 6 times
that amount. In this are included the cost of
medical care, the over-head cost in connection
"ith payment of claims, and the important in-
direct cost of loss of production. Formerly,
the affected workingman footed the entire bill
because the disease was not compensable. At
present, lead poisoning has been entered upon
the statutes of, I think, 12 states but the
worker still pays the bill in pain and suf-
fering, impaired productive power, workless
and wageless weeks and years, and consequent
lowered standard of living. It has been es-
timated that the injured workman assumes
from three-fourths to four-fifths of the finan-
cial loss attending his incapacity even under
the most liberal compensation laws.
Industry has already learned that it is
“good, business” to prevent accidents, but it
has not learned that it pays equally to prevent
occupational disease. However, among the
more enlightened of industries, where inten-
sive and sustained efforts for prevention of
lead poisoning are maintained, it is consider-
ed more than sound business to put up the
money for elimination of lead poisoning from
modern industry, or at least to minimize, if it
cannot entirely abolish, the disability resulting
from the insidious poisoning. The experience
of a few of these plants where a fair degree
of safety has been obtained points to a de-
' cided economic advantage, for safe working
conditions bring about efficiency and increased
production, reduce over-head, improve labor
relations and place rival industries at a com-
petitive disadvantage.
It is rather interesting, though regretful, to
observe the methods employed by a goodly
portion of the lead industry to avoid payment
of compensation for lead poisoning instead of
preventing it and curing when it does occur.
A New Jersey plant where safety measures
were few and the hazard great employed a
system of signing up each employee as an in-
dependent contractor at the time of applica-
tion for employment. Another plant would
discharge grumbling Portuguese and employ
satisfied Negroes. A third would reject
the ungrateful Negroes and engage the meek,
but thankful Portuguese. It so happened that
there was a mutual exchange of poisoned em-
ployees. I have also observed some men being
ill with lead poisoning and who were given
certificates for grippe, influenza and gastritis.
However, industry as a wdiole is willing to co-
operate and eradicate lead poisoning from its
midst piovided it is given the proper incen-
tive and guidance.
1 hat a true case of lead intoxication usually
leaves an indelible imprint upon the human
system and causes permanent pathologic
changes no one disputes. Nor is it denied that
poisoning by the same metal may terminate
fatally. It is. furthermore, generally conceded
that a mild case may produce some temporary
discomfort without permanent pathologv. Tes-
tifying before the Newark, New Jersey, Com-
pensation Bureau, Dr. Joseph C. Aub stated
that encephalopathy and peripheral nerve
changes may be permanent in nature, but he
had no evidence to prove or disprove other or-
ganic changes. The following week I spoke to
Dr. E. R. Hayhurst who assured me that
chronic lead poisoning invariably produces
nephritic changes and may result in a con-
April, 1931
JOURNAL OF THE MEDICAL SOQIETY OF NEW JERSEY
329
traded kidney. Subsequently, at a symposium
on occupational diseases, Dr. Harrison S.
Martland stated that, in treating cancer with
colloidal lead, patients were all cured of their
cancer but died of lead poisoning. Professor
Chaves and Dr. Levin of the Berlin-Lank-
owitz Hospital made a study of 1500 cases
diagnosed as lead poisoning and came to the
conclusion that “organic changes in the blood,
the kidneys, nervous system, intestinal canal
and liver can rightfully be attributed to the
action of lead”.
The conditions enumerated in the preceding
paragraph illustrate some of the factors en-
tering into the computation of disability, the
true measure of which is the amount of im-
paired function and physical incapacity re-
maining after all acute manifestations have
disappeared. It has been established that in
true cases of lead intoxication the lead is
stored in the long bones of the body. After
an apparent recovery the accumulated lead is
subject to sudden liberation and mobilization
into the circulation by so slight an agency as
the common cold, change in diet, or ordinary
fatigue which, while having no effect on the
every day worker, is sufficient to disturb the
acid-base equilibrium and reactivate the lead
poisoning long after cessation of exposure.
This condition lessens the worker’s earning
capacity, increases the number of workless
days per year, reduces the period of “work
expectancy” and with other sequels contributes
to a shorter span of life.
Temporary Disability. In lead poisoning
this is the period during which the affected in-
dividual is incapacitated from any work on
account of acute manifestations of the disease.
The most distressing symptoms at this time
are the severe colic, intense headache, and gen-
eral asthenia. Duration of this period is ex-
tremely variable, depending upon many fac-
tors, such as age and sex of individual, length
of exposure, compound exposed to and, above
all, the susceptibility and idiosyncrasy of the
individual. This period of disability varies
greatly with the particular systems or organs
involved in the exposed individual. If the
poison attacks the brain or the nerves and their
endings, the period is longest, while in cases
with predominating cardiovascular disturbance
the period is shorter, and it is still further re-
duced if the symptoms are confined to the
gastro-intestinal tract. Generally speaking,
the period of temporary disability in industrial
lead poisoning varies from 2 or 3 weeks to
several months, and considerably longer in
cases of encephalopathy.
P ermanent Disability. This is the residual
damage or permanent pathology left after the
individual is removed from further exposure,
and medical and physical measures instituted,
and sufficient time has elapsed to allow the or-
dinary consequences of the disease to disap-
pear by medication and elimination. Generally
speaking, this residual damage is greatest in
the cerebrospinal type of cases, because of the
nature of brain tissue. Injury by the lead di-
rectly, or through the damaged blood vessels
indirectly, is permanent in character because
damaged brain tissue does not regenerate.
This is the most distressing form and may be
characterized by headache, tremors, neuras-
thenia, hallucinations, convulsions or epilepti-
form seizures, or even insanity. Similarly, the
neuromuscular type exhibits muscular weak-
ness, atrophy and even muscle group par-
alysis. The permanent pathology in the car-
diovascular group is referred to the second-
ary anemia and to local changes in the organs
supplied by the sclerotic vessels. The gastro-
intestinal form is milder in its permanent ef-
fects, the individual suffering at most from a
persistent constipation and recurrent colic.
To determine the permanency of the path-
ology and its resulting disability I have follow-
ed a great many cases from inception until
the present date. The following data are
based on a study of over 200 cases of indus-
trial lead poisoning that have come under my
observation during the last few years. No
cases were included in the series unless, at the
onset of the disease, they presented the fol-
lowing cardinal signs of lead intoxication :
History of exposure to lead, colic or epigastric
distress, stippling of the red blood cells, and
usually presence of lead in the urine. It is ap-
parent that the deductions as to permanency
of the pathology would not apply to all cases
of alleged lead poisoning because, as a rule,
those not presenting the cardinal signs were
regarded as temporary in nature and excluded
from the series. About 50% of these cases
330
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
have cleared up and left no appreciable disa-
bility, or have not reached the stage where
permanency could be established. Due to lack
of space and time, the details of 12 cases and
a resume of about 85 others constitute the
basis upon which the conclusions are reached.
These have been under my observation from
1 to Al/> years.
Case 1. February 22, 1929. J. S., male,
white, single, 31, Portuguese, lead furnace
worker, working 7 days a week. Cramps in
stomach, vomiting spells, dizziness, headache,
weakness in hands and feet.
Blood: Hb., 76%; R. B. C., 4,000,000; W.
B.C., 6500; 85 stippled cells per 100 leuko-
cytes ; moderate poikilocytosis ; anisocytosis
and polvchromophilia. Urine: Sp. Gr. 1.013;
occasional hyaline cast ; lead present.
February 30, 1930. Persistent constipation;
occasional cramps ; headaches ; dizziness ; loss
of sight; general weakness, particularly hands
and feet; loss of memory.
Physical examination : Lead line on gums ;
blanched membranes ; tenderness over epigas-
trium ; pupils react but very sluggishly, right
more than left; diminished knee jerks; masked
facies ; blepharospasm ; triceps reflex diminish-
ed ; retinal hemorrhages ; arteriosclerosis ;
sclerotic vessels in retina.
Case 2. March 18, 1929. J. C., male, white,
married, 33, Portuguese laborer, furnace
worker in smelting plant. Cramps in stomach,
vomiting, headache, dizziness and muscular
pains.
Blood: Hb., 58%; R. B. C., 2,900,000; W.
B. C., 6800; stipples 200 per 100 cells;
poikilocytosis ; anisocytosis ; and polychromo-
philia. Urine: Lead present; trace of albumin;
hyaline casts numerous ; occasional granular
casts.
July 21, 1930. Cramps, persistent constipa-
tion, fatigue on moderate exertion, occasional
attack of colic, recurrent headaches and im-
paired vision.
Physical examination : Remains of blue
line on upper gum ; dull facial expression ;
pupils widely dilated; tremor of tongue and
extended fingers. Blood shows a mild second-
ary anemia. Urine: Albumin, hyaline and
granular casts ; negative for lead.
Case 2. December 6, 1928. P. McR., male,
colored, married. 33, American laborer, clean-
ing tanks where colors and paints are mixed,
worked 9 hr. a day, 5% days a week. While
working, was taken suddenly ill with severe
cramps, vomiting, headache, dizziness, and
general weakness.
December 22, 1928. Blood: A few stippled
cells. Wassermann negative.
January 12, 1929. Urine: Faint trace of
albumin ; many hyaline and granular casts ;
lead present. Blood: Hb., 45%; R. B. C.,
3,250,000; W. B. C„ 5250.
April 9, 1929. Blood : 'Stipples — 36 per 100
cells ; marked poikilocytosis ; moderate aniso-
cytosis and polvchromophilia. Urine: Strongly
positive.
September 6, 1929. Weakness, occasional
colic, pains in joints and back, general pallor.
Urine: Lead present; hyaline and granular
casts. Blood : Hb., 68% ; R. B. C., 3,600,000 ;
W. B. C., 4200; occasional stipples.
Physical examination: Arcus senilis; left
disc pale ; pupils react ; tachycardia ; diminish-
ed knee-jerks; hypesthesia of lower extrem-
ities.
June 30, 1930. Cramps, pain in back, weak-
ness of muscles, particularly wrists, persistent
constipation, easily fatigued.
Case 4. March 1929. J. R., male, single,
white, 28, Portuguese laborer, working on lead
furnance in smelting plant 7 days a week.
Severe cramps, vomiting spells, dizziness,
weakness, constipation and severe pains in
both legs. Blood: Hb., 78%; R. B. C., 4,100,-
000; W.B.C., 7400; 40 stipples ; polychromo-
philia. Urine: Lead present; occasional hya-
line cast; Wassermann negative.
January 24, 1930. Headache, dizziness, ver-
tigo, diplopia, defective memory, weakness of
arms and legs, particularly left arm.
Physical examination : Irregular, intermit-
tent heart ; enlarged liver ; normal reflexes and
gait ; very slight tremor of fingers ; slight hy-
palgesia ; hypesthesia ; good general muscular
response to electric reactions.
Case 5. January 1929. M. N., male, white,
married, Portuguese, 41, laborer working on
lead furnace 11 hours a day and 7 days a
week. Pains in stomach, very weak and tired in
legs, vomiting, “funny taste in mouth”, “head-
ache that makes everything turn around when
April. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
331
standing up”. Blood : Hb., 70%; R.B.C., 4,-
i 00, 000 ; W. B. C., 8000; marked polychromo-
philia ; slight poikilocytosis ; anisocytosis ; 18
stippled cells. Urine: Negative for lead.
January 14, 1930. Headache, dizziness,
weakness of arms and legs, poor vision in one
eye, loss of weight.
Physical examination : Blue line on gingival
margin; cyanosis of hands and feet; general
tremulousness and general increase in deep re-
flexes ; electric reactions show the upper ex-
tremities to react well while the lower, espe-
cially the right leg, does not react so well ;
eye-grounds reveal some signs of optic atrophy
which may be due to the lead poisoning.
Case 6. March 23, 1929. A. M., male, white,
married, 38, Portuguese, lead furnace man in
smelting concern, worked 7 days per week.
Cramps in stomach, loss of appetite, dizziness,
headache, vomiting, dry throat, generalized
weakness and persistent constipation.
March 20, 1929. Blood : Numerous stip-
pled cells.
March 26, 1929. Blood: Hb., 60%; R. B.
C., 3,000,000; W. B. C. 5200; 100 stipples;
poikilocytosis ; anisocytosis, and polychromo-
philia. Urine: Positive for lead.
December 29, 1930. Loss of vision which
is periodic in nature, nervousness, weakness
of extremities, difficulty of speech and con-
stipation.
Physical examination: Waxy yellow skin;
restless eyes ; fine tremor of extended fingers
and protruding tongue ; dyspnea ; abdominal
reflexes equal 'and active; right ankle- jerk ab-
sent ; hypalgesia and hvpesthesia over all ex-
tremities ; extensor weakness ; eye-grounds re-
veal optic atrophy.
Case 7 . December 1929. A. B., male, white,
35, Portuguese, married, lead furnace worker
for 3 years, worked 7 days a week. Sudden
attack of dizziness, weakness, pain in stomach
and fell unconscious while at work. Blood:
Secondary anemia and marked stippling.
Physical examination: Well developed in-
dividual ; pale ; sallow expression ; gait, steady ;
abdominal tenderness ; exaggerated reflexes ;
extensor weakness.
January 1931. Constipation, headache and
insomnia.
Physical examination : W ell-nourished and
muscular; somewhat anemic; frightened
facies; expression pinched; waxy skin; un-
steady gait ; general . tremors ; pupils slightly
unequal, right larger than the left ; discs
pale ; vessels over-filled and tortuous ; throm-
bosed veins in center of right disc ; all
reflexes exaggerated tremendously. B. P.
142/80. Tuning fork, air conduction less on
left side. Loss of tuning sensation. Marked
tremor of tongue and extended fingers.
Case 8. October 15, 1929. A. D., male,
white, 32, married, lead furnace tender, work-
ed 7 days per week. Headache, dizziness, pain
in abdomen, weakness in extremities, nausea,
vomiting, impaired vision. Blood: Hb., 65%;
R. B. C., 3.900,000; W. B. C., 6500; color in-
dex, 0.9; polynuclears, 57%; small lympho-
cytes, 33 ; large lymphocytes, 8 ; endothelial
cells 2 ; 125 stippled cells per 100 leukocytes ;
R. B. C., achromatin ; anisocytosis; poikilo-
cytosis ; and polychromophilia.
October 15, 1929. Physical examination:
Pallor of skin and mucous membrane 'of
mouth and conjunctiva; epigastric tenderness;
extensor weakness.
January 1931. Physical examination: Pale;
unsteady; atrophy of left arm; Romberg posi-
tive; exaggerated knee-jerk; practically no
plantars; slight optic neuritis; retina pale (on
both sides) ; vessels congested; hvpesthesia of
left side of chest and legs; general tremors;
atonic facies ; corneal anesthesia ; epigastrium
still tender.
Case 9. April 27, 1928. J. C., male, white,
married, 36, Portuguese, previous occupation
agricultural laborer, taking molten lead and
copper from the furnace. Became ill in April
1928. Date of last exposure — April 27, 1929.
Cramps, dizziness, nausea, vomiting, general
weakness; subsequently faintness followed by
unconsciousness. Blood: Hb., 83%; R. B. C.,
4,600,000; W. B. C., 6800; 32 stipples, nor-
mal as to size and form. Urine: Negative, ex-
cept for few blood cells. Wassermann nega-
tive.
November 2, 1929. Epileptiform seizures
growing more frequent in duration and lasting
longer. Had attacks on street and once in sub-
way. Epigastric tenderness, tearing head-
aches and general weakness.
Physical examination : Pale waxy skin ;
332
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
cadaverous mask-line facies; appears indiffer-
ent and phlegmatic ; heart sounds below par ;
B. P., 115/90; slight involvement of the up-
per left chest, subcrepitant rales; sclerosis of
retinal vessels ; abdomen-epigastric tender-
ness and right rectus rigidity. Reflexes — in
creased triceps, biceps, ulnar and radial ; mark-
edly increased knee and Achilles reflexes; left
Babinski. Bilateral papillitis. Extremities
cyanotic, skin dry — diaphoresis. Blood: Nu-
merous stippled cells. Urine: Albumin, hya-
line casts; R. B. C., and W. B. C.
Case 10. July 1929. A. F., male, white, 36,
Portuguese, single, tap man in lead furnace,
worked 7 days a week. Loss of appetite,
muscle weakness, headaches, cramps, vomit-
ing. Blood: Marked stippling. Hb., 43%.
Urine: Positive for lead. Physical examina-
tion : Well developed ; rather pale ; waxy,
pinched expression ; tender over epigastrium.
May 31, 1930. Physical examination: Ap-
pears aged ; hair gray ; masked facies ; slow
arid unsteady gait; cadaveric skin; pale con-
junctiva; slight facial paralysis. Blood: Hb.,
50%; R. B. C., 3,250,000; W. B. C„ 5000;
color index, 0.8 plus ; polynuclears, 50% ;
lymphocytes, 48% ; endothelial cells, 2% ; 35
stippled cells per 100 leukocytes ; red cells
show anisocytosis ; poikilocytosis and poly-
chromophilia.
January 1931. Headache, dizziness, weak-
ness, impaired vision, deafness in right ear,
progressive constipation and facial paralysis,
loss of weight, insomnia. Physical examina-
tion : Anemic ; lacks initiative ; pupils react to
light and accommodation; slight nystagmus;
eye-grounds distinctly blurred ; retinal veins
tortuous and engorged with a definite optic
neuritis. Facial paralysis very marked. All
reflexes sluggish except right knee which is
exaggerated. Hands tremulous ; station un-
steady ; speech defective.
Case 11. November 1928. P. R., male, white,
single, 48, Ukrainian, grinder and weigher in
color and pigment plant for 5 or 6 years.
Working 11 hours a day and 7 days a week.
Cramps in stomach, back and chest, itching
over whole body, vomiting, dizziness, sweet
and bitter taste in mouth, constipation and
shaking. Blood: Hb., 87%; R. B. C., 4,400,-
000; W. B. C., 7000; no stippled ceils or
poikilocystosis ; normal as to size, form and
staining. Urine: Negative for lead; albumin
and casts present. Wassermann negative.
Feces positive for lead.
February 1930. Physical examination:
Masked facies ; general and muscular develop-
ment fair ; heart and lungs negative ; defective
speech ; persistent nystagmoid movements of
the head ; pupils react normally ; generalized
tremors ; marked intention tremors ; general
weakness of extensors; sensory areas of anes-
thesia, in upper extremities and hypesthesia in
lower ; mentally retarded ; hyperemotional and
too excited to answer simple questions.
This man is totally incapacitated for any
kind of work although part of his pathology
may possibly be attributed to a head injury he
sustained about 15 years ago. However, he
did not lose any time from work during the
preceding years.
Case 12. February 1926. I. B., male, white,
married, 54, American, painter for 15 years.
General weakness, colic, dizziness, dropped
to the ground while at work and unable to
work. Blood : Large amount of stippling.
Urine : Lead present.
April 1926. Began to feel lazy, had no am-
bition, lost appetite, was constipated, had pe-
culiar nasty taste in mouth every morning,
constantly increasing headaches, dizziness and
nausea. Both wrists were losing strength so
that he was unable to hold brush.
April 19, 1926. Felt sick at stomach, had
sharp cramps, got red in the face, and had
pains in arms and legs. Collapsed and taken
to the hospital where he remained for 6
months.
January 2, 1929. Physical examination: Pa-
tient developed advanced encephalopathy.
Nystagmoid movements of head; generalized
tremors; paralysis of extensors of both fore-
arms ; weakness of extensors of legs ; unable
to do work of any kind.
January 22, 1931. Physical examination:
Condition unchanged ; double wrist drop ; legs
weak, tremors more pronounced; unable to do
any work.
In addition to the 12 cases cited, about 90
others have been followed periodically and the
findings recorded. While a series of 102 cases
is far too small a number upon which to base
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
333
definite conclusions, nevertheless, the repeat-
ed clinical manifestations and objective find-
ings as disclosed in the periodic examination
clearly point toward definite pathology as
shown in the following table :
The subjective and objective symptoms of
this group in the order of their frequency and
their percentages were as follows :
Subjective
Persistent headache 70%
Dizziness 60%
Obstinate constipation 52%
Muscle group weakness 48%
Premature fatigue 36%
Epigastric pains 35%
Visual disturbances’ 33%
Arthralgia 32%
Shakes 32%
Insomnia 20%
Periodic vomiting 18%
Loss of weight 14%
Objective
Anemia 60%
Eye-ground changes 33%
Tremors 32%
Unsteady station 25%
Hypesthesia and hypalgesia 20 %
Nephritis 18%
Arteriosclerosis (premature) 16%
Lead line 16%
Cardiac lesions 12%
Retinal hemorrhage 11%
Facial palsies 10%
Dyspnea 9%
Wrist and ankle drop 5%
Convulsions 2%
While the subjective symptoms may have
been exaggerated wilfully or as a result of an
anxiety neurosis, nevertheless, the physical
signs, ophthalmoscopic findings and laboratory
examinations, demonstrated the physiologic
basis for their abstract complaints.
In reply to a questionnaire sent to the medi-
cal officers of 30 life insurance companies
scattered throughout the United States and
Canada we received the advice that a man
who had suffered from industrial lead poison-
ing would not be issued ordinary life in-
surance and would be “rated” up for a sub-
standard form of insurance. Practically
none would issue health insurance or attach a
disability clause to the policy. While this is
not conclusive, it is rather significant, in view
of the attitude of the insurance companies that
base their opinions on past experience.
Observations
(1) Wrist drop was comparatively rare,
with the exception of the painter who used his
wrist muscles more than the others.
(2) The blood picture is of diagnostic sig-
nificance and is indicative of the intensity of
the disease in the acute and subacute stages.
It is of no import in the chronic stage since
the most seriously affected of that group —
those who are permanently and totally dis-
abled— displayed a practically normal blood.
(3) Persistent headache, dizziness, consti-
pation, general weakness, visual disturbance,,
muscle and joint pains, in their respective or-
der, are the chief complaints of the patient
suffering with chronic plumbism ; the other
symptoms are just as definite, but less fre-
quent.
(4) Workers in different industries, where
different compounds or processes are used,
display different clinical pictures and blood
findings. The white lead workers showed a
persistently low hemoglobin ; the smelters a
low red blood cell count; and the lead battery
workers an arthralgia and myalgia.
(5) Workers with chronic plumbism are
ready victims for intercurrent diseases, par-
ticularly tuberculosis. Incised or lacerated
wounds “fester” and the duration of the or-
dinary cold is out of proportion to its severity.
(6) Over-worked men have a longer period
of temporary disability and are subject to
most residual damage. The more seriously^
affected of the group were those who worked
7 days a week and 10-12 hours a day. Appar-
ently in these individuals elimination did not
keep pace with absorption and the accumu-
lated balance resulted in permanent disability.
(7) The length of exposure was of no-
material significance. Some men with 2 or
3 weeks’ exposure suffered from a more in-
tense attack and were left with greater disa-
bility than those with long years of exposure.
Conclusions
(1) A mild case of lead poisoning may
leave no permanent disability.
(2) The gastro-intestinal type of lead
poisoning is of a temporary nature and the
resulting persistent constipation is not disab-
ling in character.
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
(3) The cerebrospinal form of lead poison-
ing is the most distressing in its fnanifesta-
tions, most destructive in nature, most per-
manent in character and may result in total
permanent disability.
(4) The kidneys usually show the most
degenerative changes.
(5) Long hours and over- work are con-
ducive to greater disability.
(6) Chronic lead poisoning sufferers have
a lowered resistance, are poor risks for health
insurance, and have a shorter life expectancy.
May I mention, in closing, that our follow-
up work and examinations of this group,
though by no means perfect, have revealed
that these men have been suffering intensely
and persistently. 1 could not escape the feel-
ing, although I cannot produce the legal proof,
that once a man suffers from a severe indus-
trial lead intoxication he never completely re-
covers from it and carries the sequels to the
end of his days.
DIFFERENTIAL DIAGNOSIS OF LEAD
POISONING
Joseph S. Mark, M.D.,
Woodbridge, N. J.
Of late years, during the development of
industrial medicine and surgery as a specialty,
much has been written concerning lead intoxi-
cation, and attention of the profession has
been clearly drawn to consideration of this
condition when facing indefinite complaints by
workers employed in lead hazardous occupa-
tions. In fact, the emphasis has been so great
that there exists a very definite danger of
overlooking the fact that a man can be so
employed, even show evidence of lead ab-
sorption, and yet his complaint may be patho-
logically due to some other, intercurrent con-
dition. This danger is enhanced by the fact
that often the symptoms of lead intoxication
are manifold and indefinite, and may so easily
be confused with chronic conditions the symp-
toms of which are similar. ' As lead intoxica-
tion is the diagnosis of least resistance, in-
tercurrent conditions can easily be neglected,
and it requires, an exceptional amount of zeal
and diagnostic acumen to pursue investigation
further, when a lead hazard employee com-
plaining of indefinite symptoms, showing
basophilic stippling and some anemia, pre-
sents himself for diagnosis. And yet, quite
frequently, if sufficient time is allowed to
elapse to allow his pathologic condition to be-
come diagnostically definite, any one of a num-
ber of chronic diseases may establish its
presence.
In order -to discuss differential diagnosis
more intelligently, I would like to enumerate
briefly the salient signs, symptoms, and labora-
tory findings in lead intoxication.
Clinical picture. As a rule, the symptoms
are rather indefinite and gradual in their on-
set. The patient first notices that his appetite
is diminishing. There follows some sleepless-
ness, headache, constipation, easy fatigue, ir-
ritability, nervousness, inability to concentrate
and, occasionally, indefinite abdominal pains
and nausea. These symptoms might mani-
fest themselves a few weeks after the begin-
ning of exposure, and sometimes not for
years, depending on individual susceptibility.
As a rule, if a man works for 6 months in
the presence of a lead hazard without any of
the prodromal signs just described, his sus-
ceptibility is rather high, and with care he
will not develop lead intoxication. As the con-
dition advances, there appears a characteristic
pallor. There is a uniformly grayish color- of
the face, like the appearance often noticed in
miners, or people working constantly at night
occupation where little exposure to sunlight is
obtained. It is often surprising how slight is
the loss of hemoglobin as compared with the
pallor of the face. It is difficult to avoid be-
ing misled by Spaniards, Portuguese or other
people whose color is normally grayish and
pallid. There develops a very fine tremor, in-
tentional in character, beginning around the
ocular and buccal sphincter muscles, especially
noticeable when the patient is requested to
bare the upper gums or approximate the eye-
lashes without shutting the eyes entirely.
Later, there is a tremor of the fingers and
hands, demonstrable when the patient is re-
quested to hold out the arms and hands
straight and separate the fingers, and to main-
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
335
tain that position for a few minutes. Also
there is a gradually increasing weakness of
the tensor muscles of the fore-arm demon-
strable by having the patient flex and extend
the wrist against resistance measured by spring
scales or weights. In far advanced cases, as
is well known, there is a wrist-drop, and
foot-drop. Meanwhile, loss of appetite is in-
creasing; he will carry his lunch home un-
touched. Constipation, which only very large
doses of cathartics will remedy, becomes
severe. There will be indefinite collicky
pains and marked fulness in the epigastrium;
metallic taste is often complained of ; head-
aches and insomnia increase ; fleeting pains
along the peripheral nerves and joints but no
real arthritis or neuritis. In some cases, con-
junctival jaundice is in evidence, and the well
known Burtonian line, or lead line, develops.
Sometimes there is a mental change ; irritabil-
ity, forgetfulness, nervousness. I need hardly
mention lead colic, for it has been often de-
scribed and well impressed on the clinician,
except to say that it is usually a late symptom ;
but when present it clinches the diagnosis. In
fact, lead colic is not present so frequently
as general opinion would indicate. Encephalo-
pathies occur, manifested by epileptiform
seizures, convulsions, and even coma, but
these are fortunately rare and late manifesta-
tions. Ocular disturbances also occur, rang-
ing from paralysis of the external muscles to
real optic atrophy. There are some symptoms
mentioned in text-books which have never
been proved to be due to lead, and which,
clinically, I have never been able to accept as
such; i.e., arteriosclerosis, hypertension, or-
ganic kidney changes, organic joint changes.
The symptoms above described may all co-
exist or may be present at different times. In
the majority of cases, some of these symptoms
are strikingly in evidence, others negligibly.
It is by a combination of symptoms and signs,
and by their extent and correlation, that we
are guided to a diagnosis.
Laboratory findings. The blood picture is
very distinct. There is a diminution of hemo-
globin, which is rarely lower than 65% ;
anisocytosis and poikilocytosis ; diminution of
the red cells, but rarely lower than 3,500,000 ;
the white cell and differential counts are not
altered. Basophilic degeneration or stip-
pling of the red blood cells is present to a
varying degree. I have been in the habit of
estimating these cells quantitatively in rela-
tion to 100 white blood cells, and less than
6 stippled cells is not considered pathologic.
There exists considerable difference of opinion
as to the prognostic value of the number of
stippled cells present. I am convinced that
the presence of stippled cells in the blood
in excess of 6 to 100 leukocytes, when the
primary anemias, leukemias, malaria and
benzol poisoning can be excluded, is indica-
tive of just one thing — absorption of lead
into the system. Whether or not the lead
thus absorbed is causing poisoning, stippled
cells will not tell us. In a frank case of
poisoning it will not tell either the severity or
progress. Attaching any further significance
to the presence or quantitative determination
of stippled cells is the one great stumbling
block of the. differential diagnosis of lead
poisoning. I have followed men who have
shown consistently stippled cell counts, vary-
ing from 10 to 300, for years, who have not
lost a day from work because of illness nor
shown any other symptom of lead poisoning.
Men can have severe cases of lead poisoning,
and show very few stippled cells. The absence
of stippled cells, on repeated examinations, is
a distinct evidence of freedom of the system
from lead; or to put it differently, no lead
poisoning can be present if no stippled cells
are found on repeated examination.
Presence of lead in the feces shows the en-
try of lead into the gastro-intestinal tract.
Whether it has been swallowed and passed
through, or reabsorbed from the blood stream,
it is impossible to state. Presence of lead in
the urine shows that lead has been absorbed
and passed through the system. The presence
of lead in either feces or urine or both simply
shows absorption, not necessarily poisoning.
Further symptoms and signs are required to
diagnose poisoning, with these laboratory
findings as corroborative evidence.
The diagnostic value of the lead line is in
the same category as the laboratory findings.
Its presence indicates lead in the system, but
not necessarily poisoning. Its absence does
not preclude lead poisoning. It must be noted,
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
in passing, that Arabs and Turks have natural
bluish spots or their gums which must not
be confused with a lead line.
Differential diagnosis must be discussed in
relation to 3 distinct groups: (1) Frank cases
where no unusual difficulties are present. (2)
Frank cases where lead poisoning is claimed
but the indications are clearly negative. (3)
Borderline cases, where it is necessary to use
extreme care to arrive at a diagnosis.
Group 1. Lead colic is relatively simple to
differentiate, although there are a few con-
ditions with which it might be confused. Ap-
pendicitis shows more localized pain, tender-
ness, and rigidity. In lead colic, the signs
are referable to the upper abdomen, as a rule,
and rigidity is generalized and intermittent.
There is seldom more than 1° elevation in
temperature in lead colic, and no leukocytosis.
It is possible to have acute appendicitis in cases
where stippled cells and lead line are present.
Peptic ulcer about to perforate the serosa will
give symptoms resembling lead colic; the on-
set of pain is more abrupt, and tenderness and
rigidity are localized to the right side of the
-epigastrium, while in lead poisoning they are
more generalized. Cholelithiasis, nephro-
lithiasis, tabetic crises, and kinks of the ureter,
must also be considered, but they have charac-
teristic signs and need no further discussion.
Hypodermic injections of morphin sulphate in
adequate doses will relieve these conditions,
but are not so apt to relieve the pain of lead
colic. Intravenous injection of calcium
chloride or gluconate will relieve lead colic but
will have no effect in the other conditions.
Atypical cases of angina pectoris must also be
considered, but the direction of the pain, being
referred to the left shoulder and arm, the
facies, the absence of abdominal rigidity, his-
tory of previous similar attacks and hyper-
tension will clarify the diagnosis. Wrist-drop
and foot-drop are easily diagnosed, but in
some cases alcoholic neuritis, slowly develop-
ing polyomyelitis, and progressive muscular
atrophy must be considered.
Group 2. Workers in factories where
propaganda has been undertaken to prevent
lead poisoning often come to the medical ad-
viser with the home-made diagnosis of lead
poisoning but with conditions which may be
anything from acute follicular tonsillitis to
eczema. I mention these cases only to warn
the clinician not to accept readily the diag-
nosis just because the patient has been ex-
posed to a lead hazard.
Group 3. It is in cases where indefinite
symptoms with no distinct physical signs are
present that the greatest care must be exer-
cised. Every case must be decided on its own
individual merits and diagnosis arrived at by
correlating the symptoms, by careful valua-
tion of the significance of prominent symp-
toms present, by taking into consideration the
suggestive help of less striking symptoms, and
the corroborative evidence of the laboratory
findings. As a rule, where gastro-intestinal
symptoms are present, a lead line is evident,
pallor is striking, constipation marked, and the
blood picture is positive, the condition must
be treated as lead intoxication until disproved.
Among conditions most closely resembling
lead intoxication, chronic alcoholism is most
frequent and must be seriously considered. It
will produce the gastro-intestinal signs and
symptoms, the tremors, headaches, insomnia,
and nervous manifestations. It will cause peri-
pheral neuritis, often blamed on lead. Chronic
alcoholism predisposes to lead intoxication, and
for that reason alcoholics should be removed
from where lead hazard is present. When in
doubt, consider the condition as alcoholic,
secure thorough elimination, and the patient
will be relieved ; if not, the case should be
considered positive for lead and treated ac-
cordingly. Alcohol and lead do not mix; al-
coholics show signs of poisoning early and
from relatively small amounts, and so they
seldom develop bad cases of lead intoxica-
tion and can be deleaded promptly. Tuber-
culosis in its incipient stages may be easily
mistaken for lead poisoning. The gastro-in-
testinal complaints, weakness, loss of appetite,
debilitation and pallor are common to both
conditions and very often radiographs, posi-
tive sputum, and temperature records are
necessary before a definite diagnosis can be
made. Syphilis, as the greatest imitator, has
a rival in lead poisoning, which also can
mimic a great many indefinite conditions.
General paralysis will be ruled out by the
positive Wassermann reaction; which reaction
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
337
in lead poisoning is always negative. Per-
nicious anemia, leukemias, and secondary
anemias can be ruled out by the blood picture,
although they might be combined with lead ab-
sorption.
Malingering in lead poisoning. No paper of
this character would be complete, without
some consideration of malingering. The ma-
jority of workmen exposed to lead for a long
time will absorb a certain amount, varying ac-
cording to individual susceptibility, the length
and character of exposure, health of the in-
dividual and precautions exercised. This ab-
sorption might be temporary, recurrent, or
permanent. It can be easily demonstrated by
the lead line, stippled cells, and presence of
lead in the feces and urine. Only a small per-
centage of workers will develop lead poison-
ing, if proper precautions and care are exer-
cised. Practically any of these men can, how-
ever, claim the presence of lead poisoning if
their laboratory findings are positive, and if
they can enumerate enough subjective symp-
toms which no one can disprove or deny. If
a lead line is present, they can strengthen their
case accordingly. The motive for malingering
is the money which the compensation court
might award for temporary, partial or per-
manent disability. The immediate cause for
malingering is either some grievance against
the employer, a large award recently made to
some friend, the persuasion of some lawyer’s
runner, or transfer to some other work which
is disliked. It has been my experience that a
good many men, discharged at any one time,
will promptly find their way to the compen-
sation court, being represented by the same
lawyer, complaining of the same or similar
symptoms, in spite of the fact that their em-
ployment and medical records are free of com-
plaints, or noted absences from work because
of illness. It is not easy to explain this oc-
currence on the basis of coincidence. The fol-
lowing instances may be of interest. In a cer-
tain lead plant 2 men were discharged be-
cause of acute alcoholism. On the same day
one of the furnaces was shut down for re-
pairs, and 2 men were discharged for lack of
work. All 4 men filed claims for compensa-
tion, claiming permanent disability because of
lead poisoning. In another instance, a man
filed claim for compensation because of a
slowly developing hernia. The case was de-
cided against him and he promptly changed
his plea to partial permanent disability be-
cause of lead poisoning. All of these men had
medical certificates to back their claims, the
diagnosis in each case being based on the lab-
oratory findings. The medical men did not
take into consideration the clinical findings,
because stippled cells were present. In most
of these cases the men do not consult the
physician in search of treatment; the object
is medical testimony. They are not in search
of health but of easy money. If successful,
remarkable cures are accomplished ; their
strength and health returns as if by magic,
and they find that they are able to take up the
same work once more, although often in a
different locality. There have been cases un-
earthed where the men were receiving partial
permanent disability awards from one factory,
and working steadily and full time in another.
In doubtful cases of this category, I have
adopted the following procedure. Thorough
hospitalization for a complete study of the
condition and measures used for relief of con-
ditions complained of ; if negative for inter-
current pathology, deleading and supportive
and building-up treatment. This method seems
to me ideal, for the patient is given the bene-
fit of the doubt, and if it is a true lead case
deleading and supportive treatment will cure
him ; if some other disease, it can be brought'
to light and accordingly treated; if the con-
dition is imaginary, hospital routine and in-
tensive study will bring it to light. In fairness
to the patient, temporary disability should be
paid during the period of hospitalization, and
afterward until declared again able to work,
if the debility is due to lead.
LIVER CYSTS; REPORT OF CASE
John H. Hermann, M.D.,
and
Guy B. Griffin, M.D.,
Orange, N. J.
Owing to its comparative rarity the follow-
ing case is being reported with some detail.
The Massachusetts General Hospital records
338
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
(1870-1905) show that in 1858 operations on
the liver only 6 simple cysts were found.
Case Report
Mrs. K., American, aged 32, was taken ill
at 7 a. m. August 8, 1930, with a continuous
sharp pain arising in the right upper quadrant
and radiating across the epigastrium; pain so
severe that she fainted. After she revived the
pain, still present, was accompanied by vomit-
ing and retching. A. stomach sedative cur-
tailed both vomiting and retching but the pain
persisted. At time of attack the temperature
was 102°F. (oral), pulse 92, and respirations
20. Patient slept that night, after taking a
narcotic. The following day she was seen
at 10 a. m. by Dr. Hermann, at which time
she presented the following features :
Temperature 101°F. (rectal); pulse 100;
respirations 30; blood pressure 140/82 (aus-
cultatory, prone). General examination re-
vealed nothing. Abdomen was rounded, some-
what due to fat and flatulence ; right upper
quadrant particularly prominent. Upper ab-
domen was tender to palpation, accentuated
over a small area just below costal margin in
the right mid-clavicular line. A mass was
palpated there, approximately 7 cm. in diam-
eter which seemed to extend up under the
liver; it was neither elastic nor was a hydatid
thrill elicited. Percussion note was dull over
this area. Auscultation revealed nothing.
Past history. Measles as a child. Influenza
in 1928. Two months ago (June 1930), after
returning from an automobile ride, she had an
attack of “chills and feA^er” which lasted
through the night. Again, 1 month ago (July
1930), noted some “vague pain” in the upper
abdomen which lasted a few hours and was
followed by a sensation of soreness over the
whole upper abdomen, which persisted for 8
hours accompanied by some nausea and vom-
iting. A burning epigastric pain lasting an
hour has been caused by anything eaten since
that time. Has had occasional spells of dizzi-
ness during the past month — no particular
time or relation to meals. Gravida ii ; Para ii.
Nothing unusual noted during periods of ges-
tation. Mother died of a liver carcinoma.
Laboratory findings. Blood count showed
16,600 polymorphonuclear leukocytes; the dif-
ferential was 88% neutrophiles, 10% lympho-
cytes and 2% monocytes. Urinalysis showed
1 + albumin. Stool was negative for blood.
Roentgenogram showed a distorted duodenum
and a filling defect in the pylorus which was
irregular and suggestive of malignancy.
Due to the foregoing data, and because of
the persistent pain, an exploratory laparotomv
was decided upon.
Operation: On August 15, 1930, under gas-
oxygen induction and ether maintenance, a
right rectus incision was made. The mass was
seen to be cystic and extended inferiorly from
the porta hepatis to about 4 cm. below the liver
border; laterally from about 5 cm. left of
the round ligament of the liver to approxi-
mately 9 cm. to the right of that structure. It
was firmly attached to the round ligament and
contiguous liver surface; the gall-bladder was
not adherent. The pylorus and duodenum
were compressed and inflamed. When the
pressure was removed, contour of both stom-
ach and duodenum was normal ; no adhesions
were noted. The cyst was incised and found
to have 7 connecting secondary sacs A^arying
from 2-6 cm. in diameter. The sacs Avere
evacuated of 250 c.c. clear, serous fluid and
5 c.c. inspissated pus. A portion of the wall
Avas resected for pathologic examination.
There was no visible connection with either
the common bile duct or the gall-bladder. Tavo
cigarette drains were placed into the cyst and
the opening sutured to the peritoneum. A
similar drain was placed in the abdominal cav-
ity terminating near the porta hepatis. Reten-
tion sutures were taken and the layers of the
abdominal wall were closed separately. There
was little blood lost and the patient stood the
intervention Avell.
Laboratory report. The pus was sterile and
neither booklets, scolices nor biliary elements
were found.
Pathologic report. From the portion re-
sected, Dr. Harrison Martland could find no
evidence of malignancy or hydatid disease,
and he diagnosed the tissue as coming from a
simple cyst of the liver.
Convalescence was uninterrupted. The
wound closed cleanly and the patient was dis-
charged August 30, 1930. She has since been
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
339
seen at frequent intervals and is apparently in
the best of health. The former abdominal pain
and discomfort after meals are entirely gone.
Liver Cysts
It is almost as difficult to give a satisfactory
discussion of cysts as it is of general tumors ;
there are so many varieties and so many ex-
ceptions. A cyst may be defined as a well cir-
cumscribed, pathologic collection of fluid,
tending to persist and increase (McFarland).
Not including cysts of the gall-bladder or ex-
trahepatic ducts, those found in the liver may
he classified as follows :
Hydatids. Due to infection of the larval
form of the Tenia echinococcus; the diagnosis
being based upon a minimum of symptoms.
Brum considers the reaction of Weinberg of
no practical value and although a 2-5% eosino-
philia was confirmed at operation as echino-
coccus infection in 80% of 147 cases, he places
little importance upon this finding. In only 2
cases was the hydatid thrill elicited and he
observes that : ( 1 ) There are no clinical symp-
toms manifest so long as the cyst remains
small and hidden. (2) When it does become
exteriorized there is only 1 symptom : tumor.
(3) The biologic reactions have no practical
value.
Intrahepatic biliary cysts. From continued
obstruction the intrahepatic ducts may be
widely dilated. The contents may be thick,
inspissated bile with a healthy gall-bladder, or
colorless bile when the gall-bladder is unable
to cause concentration. This condition has
been termed “hydrohepatosis” by Rous and
McMaster. Occasionally small retention cysts
are seen associated with cirrhosis.
Cysts due to multiple adenomas. These are
small and develop at the expense of the epi-
thelial cells of the intrahepatic biliary canalic-
uli. Because of this they are thought
(Scalone) to be the most important of all
cystic new-formations in the liver.
Simple cysts. These may be single or
present in small numbers and may be due to
biliary retention, although when large the bile
may disappear and the fluid then become
■colorless. Constantine and Duboucher con-
sider their origin the same as cystic disease.
A single cyst not parasitic or due to change
in an adenoma of the bile ducts may contain
much fluid ; in Bayer’s and Winckler’s cases
6.5 liters. Cousins reported an instance in
which a cyst of the liver contained 2 % gal-
lons (11.3 liters) of clear, limpid, yellow fluid.
Like simple cysts of the common bile-duct
females provide the vast majority of the cases;
out of 56 cases, 44 were females (Jones).
The clinical symptoms are essentially those
of hydatid cysts (q. v.) from which they can
be distinguished by an examination of their
contents. Jaundice has sometimes been noted
(Doran and Munk). Very severe symptoms
may be caused by extensive hemorrhage into
or rupture of a cyst.
Pseudo-cvsts. These are due to softening
down of sarcomatous or carcinomatous nod-
ules; here the contents may be blood stained
or clear but the former occurs in the majority
of cases. In either event a microscopic ex-
amination of the cyst wall should show some
evidence of malignancy.
In general, diagnosis of liver cysts is ex-
tremely difficult and depends almost wholly
upon a microscopic examination of the con-
tents and a section of the wall. According to
Jones, Ivilvington of Melbourne, where hy-
datid cysts are common, made the correct
pre-operative diagnosis in an instance of non-
parasitic cyst, his criterion being that the fluid
tension was less than in the ordinary hydatid
cyst. Clinically, apart from hepatic enlarge-
ment or the presence of cysts which have been
known to simulate ovarian cysts or a dilated
gall-bladder, symptoms pointing to the liver
are usuallly wanting. In a series of cases of
liver cysts reviewed by Caylor, of the Mayo
Clinic, pain was a common complaint. Jaun-
dice may be present if there is pressure on a
bile-duct. In cystic disease of the liver the
symptoms are those of chronic renal disease
from the usually accompanying megalo-
cystic kidneys, such as uremia. It is to be
noted that in large tumors of the liver the
colon is displaced downward and to the left,
while in large kidney tumors the colon lies
over the swelling (Hofmann). Excursion
of the diaphragm producing change in the
position of the tumor may aid in ascertaining
the site of the mass ; however, large cysts may
produce sufficient pressure to practically in-
hibit diaphragmatic excursion.
340
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
Treatment. Cysts that occur particularly in
connection with bilateral polycystic disease of
the kidney, as a rule, require no treatment. If
marked, they may be aspirated or resected.
The type of cyst one finds may alter the op-
erative procedure, but there are some points
that should always be observed: (1) Where
the mass is large, shock is to be guarded
against. Here, quick evisceration may result
in an acute fall in blood pressure. By slowly
decompressing the abdomen or by the sub-
cutaneous administration of pituitary extract,
prior to the sudden release of intraabdominal
pressure, shock may be avoided. (2) The cyst
should be walled off from all other abdominal
contents. This is most important in the event
that the structure is of the hydatid variety.
(3) When and if opened the contents, with a
section of the wall, should be examined im-
mediately under a microscope ; operative pro-
cedure may then be altered to accommodate
the findings.
Mortality statistics would indicate that the
most favorable procedure is to incise the cyst,
draw off the contents, and suture the cyst wall
to the peritoneum or skin. This may be done
in 1 or 2 stages and is commonly known as
marsupialization. The first stage, consisting
of suturing the unopened cyst to the per-
itoneum or skin, is followed by (second
stage) incision and drainage after sufficient
adhesions have formed. In some cases one
may enucleate the cyst in its entirety and this,
of course, is always desirable.
TREATMENT OF ACTIVE MEASLES BY
INTRAMUSCULAR INJECTION OF
RECENT CONVALESCENT
WHOLE BLOOD
Jacob Piller, M.D.,
Paterson, N. J.
Medical literature contains many articles on
the use of immune serum for the prevention
or modification of measles, but little has been
written on the use of recent convalescent
blood in the actual treatment of active measles.
Kellogg (Jour. A. M. A., Dec. 21, 1929, p.
1927) states: “Convalescent serum has been
found to be effective in preventing measles,
but it is useless as a cure, once the disease is
established.”
Rowland G. Freeman, Jr., of New York,
states : “It has been attempted to abort the
disease (measles) by the injection of 20-30
c.c. of serum during the period of invasion,
but we have had no results that would indi-
cate any benefit from this measure.”
Kato (Amer. Jour. Dis. Children, Sept.
1928, pp. 526-573) summarizes: “Convales-
cent serum has been employed in the active
treatment of a few patients with malignant
measles; when a large amount of the blood is
used, as in transfusion, the effect seems to
be beneficial.”
The following two case reports illustrate
this treatment, demonstrating the practical
abortion of fully developed measles, and im-
mediate convalescence. Whether these treated
children have developed a personal immunity, I
cannot say.
Case 1. Baby W., aged 18 months, is the
youngest of 4 children. The oldest, aged 10
years, came down with an average case of mea-
sles. About a week later the second, and then
the third child, became ill with typical measles.
The mother was reluctant to have the young-
est injected with immune serum; but when it,
too, developed the rash, after 4 days’ sneez-
ing and red eyes, she requested the treat-
ment. By this time the eldest patient was
entirely convalescent and I withdrew 10 c.c.
of his blood and immediately injected it into
the buttock of the infant. Within 24 hours
the rash was entirely gone, temperature was
normal, and the child in usual good spirits.
There was no relapse or complication.
Case 2. Baby J., aged 11 months, is the
youngest of 3 children. The oldest, aged 6
years, became ill with measles complicated by
a purulent dacryocystitis. About 10 days later,
the second child, aged 4 years, and the 11-
months old infant both exhibited the rash, af-
ter the usual prodromal symptoms. I with-
drew 10 c.c. blood from the 6 year old con-
valescent boy and immediately injected it into
the buttock of the infant. The next day the
rash and fever were gone and the child was
entirely well. The 4 year old girl ran the
usual course of uncomplicated measles.
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
341
In the first case I had little hope of any
result, as the rash was already present ; and
was surprised, as well as pleased, to see the
disease promptly checked within 24 hours. In
the second case the circumstances were also
propitious for this therapy, and the favorable
result was expected.
THE ANEMIA OF PREGNANCY
Robert A. Kilduffe, M.D.,
Director Laboratories, Atlantic City Hospital,
Atlantic City, N. J.
Possibly as an aftermath of studies in pre-
natal care, the fact that pregnancy per se may
be the cause of a varying degree of anemia is
attracting increasing attention. The phrase
“anemia of pregnancy” is more usually applied
to the severe, acute hemolytic anemia infre-
quently encountered, or to that form which,
both cytologically and symptomatically, may
present more or less resemblance to the per-
nicious form. These, however, are so symp-
tomatically evident that they are seldom over-
looked.
Of greater importance, both because it is
more common, and because without particular
effort it is easily over-looked, is a definite sec-
ondary anemia without obvious symptoms but
occurring in a large number of cases. Bland
and Goldstein1, for example, report 50 cases
in which the hemoglobin varied from 42 to
78%, and the erythrocyte count from 2.36 to
3.98 millions. Of these 92% made spontan-
eous recovery after delivery.
Lyon," in about one-third of 200 cases
studied, found a hemoglobin of less than 70%
and similar findings have been reported by
Galloway3, Moore4, Kerwin and Collins5, and
others. That these studies are of practical
importance is readily apparent, for it is ob-
vious that a woman with a definite secondary
anemia cannot be expected to stand a prolong-
ed or arduous labor as well as one whose blood
picture is normal. If, as would seem to be the
case, this condition is a common concomitant
of pregnancy, then its occurrence must be
taken into account in the conduct of prenatal
measures.
The present report records the findings, as
regards hemoglobin and erythrocyte counts, in
300 women registered in the Obstetric Dis-
pensary of the Atlantic City Hospital. The
cases were unselected in any way. The report
is based upon a single examination but, never-
theless, presents findings of distinct interest
as shown in the tables below.
TABLE I.
HEMOGLOBIN AND ERYTHROCYTE COUNTS
ARRANGED IN ACCORDANCE WITH
DURATION OF PREGNANCY
Average
Average Erythrocyte
Duration o{
Number
Hemoglobin
Count: Millions
Pregnancy: Months
of Cases
%
Gm. %
per cu.m.m.
1 — 3
12
73
10.07
4.50
4 — 6
72
72
9.93
3.73
7 — 9
216
66
9.10
3.73
From these findings it is not only apparent
that a secondary anemia was encountered in
a high proportion of the cases studied, but
also that the anemia varied in degree in pro-
portion to the duration of pregnancy, being
more marked in the last than in the first or
second trimester.
In this table both hemoglobin readings and
erythrocyte counts were averaged.
If 75% is arbitrarily taken as the lower
limit of normal, and 4,000,000 erythrocytes
similarly accepted, it is seen that in the 12
patients in the first trimester the findings
taken as an average are approximately nor-
mal. As a matter of fact, however, one of
these patients whose Wassermann (Kolmer
quantitative) was 444 0 0, had a hemoglobin
of 70 and a red cell count of 3,820,000; and
another, a hemoglobin of 69 with a red cell
count of 3,720,000.
In the second trimester the individual
variations were somewhat more marked, rang-
ing from 45-82 hemoglobin and from 2,-
640,000 to 4,300,000 red cells. Nevertheless,
evidence of anemia was found in 65, or 91%
of the 72 cases examined.
In the third trimester only 34, or 15%, had
readings within the arbitrary normal limits
outlined above, well marked anemia being
present in 87% of 216 cases.
These results, which are in uniformity with
342
those reported by others, leave little room for
doubt that pregnancy per se is a cause of a
definite degree of secondary anemia, the sever-
ity of which bears a somewhat proportionate
relation to the duration of the pregnancy.
While the occurrence of secondary anemia
in pregnancy is no longer disputed there has
been, and still is, much discussion concerning
its etiology and mechanism. Among the more
prominent theories which have been advanced
are: that the anemia is the consequence of hy-
dremia with subsequent reduction in the iron
content of the red corpuscules — in other
words that it is a chloro-anemia ; that it is the
expression of an “individual disposition” in
accordance with the general physical well-
being of the particular patient; that it results
fiom the action of a syncitial hemolysin; that
it is the product of poor hygiene or such dis-
eases as nephritis, syphilis, tuberculosis, and
so on ; that it is a continuation of a preexisting
anemia ; or that it depends upon the presence
of focal infections.
While it is quite true that any of the factors
listed may be the cause of secondary anemia,
such factors are neither present with sufficient
constancy nor found in a sufficiently large
number of cases to be accepted without re-
serve. There seems little reason to doubt that
a well-marked secondary anemia is a frequent
occurrence in pregnancy; that its etiology
and mechanism are as yet undetermined and
obscure ; and that pregnancy per se is a
definite factor in its production.
The establishment of these facts indicates
the desirability of blood examinations as an
important part of prenatal study and care in
order that patients presenting hemoglobin
leadings of less than 75% and erythrocyte
counts of less than 3,000,000 may be detected
and subjected to suitable therapeutic measures.
Bibliography
1. Bland, P. B., Goldstein, L. and First, A., Ane-
mia In Pregnancy, Jour. A. M. A., 1929, 93:582.
2. Lyon, E. C„ Anemia In Late Pregnancy, Jour.
A. M. A., 1929, 92:11.
3. Galloway, C. E., Anemia in Pregnancy, Amer
Jour. Obs. & Gyn., 1929, 17:84.
4. Moore, J. H., Anemia in Pregnancy, Prelim-
inary Report of 100 Observed Cases, Amer. Jour
Obs. & Gyn., 1929, p. 424.
5. Kerwin, W. and Collins, L. L., Hemoglobin
Estimations in Pregnancy, Amer. Jour. Med. Sc
1926, 172:4:548.
April, 1931
HIGH LIGHTS IN THE LIFE OF
ROBERT KOCH
Harry Subin, M.D.,
Atlantic City, N. J.
Robert Koch, of IClausthal, was educated in
the gymnasium of his native town, and took
his medical degree at Gottingen, where he was
very much influenced by the teachings of
Jacob Henle, whose theory of contagion may
have started Koch upon his life-work in
science. After serving in the Franco-Prus-
sian Y\ ar. he became district physician at
Wollstein, where he varied the monotony of
long journeyings over rough country roads
by private microscopic studies. He began with
anthrax, and in 18/6 wrote to the eminent bot-
anist, Ferdinand Cohn, at Breslau, to the
efi ect that he had worked out the complete
life history and sporulation of the anthrax
bacillus. About a week later, at Cohn’s in-
vitation, he gave a demonstration of his cul-
ture methods and results at thq Botanical In-
stitute in Breslau, in the presence of Cohn,
Weigert, Auerbach, Trube, Cohnheim, and
others. Cohnheim declared that Koch’s was
the greatest bacteriologic discovery yet made,
and Cohn immediately published his paper in
his Beitrage.
d his report demonstrated that the an-
thrax bacillus is the cause of the disease, and
that a pure culture grown through several
generations outside the body can produce the
disease in various animals. Koch’s results
were very much opposed by Paul Bert, but
completely confirmed by Pasteur. The next
year Koch published his methods of fixing
and drying bacterial films on cover-slips, of
staining flagellae, and photographing bacteria
for identification and comparison. Then his
great memoir on the etiology of traumatic in-
iectious diseases appeared, in which the bac-
teria of 6 different kinds of surgical infection
are described, with pathologic findings, each
microorganism breeding true through many
generations in vitro or in animals. These 3
memoirs elevated Koch to the front rank in
medical science and, through Cohnheim’s in-
fluence he was appointed to a vacancy in
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
343
the Imperial Health Department, with Loef-
Her and Gaffky as assistants. Here, he pro-
duced his important paper upon the method
of obtaining pure cultures of organisms by
spreading' liquid gelatin with meat infusion
upon glass plates, forming a solid coagulum.
When Koch demonstrated his plate cultures at
the International Congress, in London, Pas-
teur vehemently declared his approval of
Koch’s great progress. The next year was
marked by discovery of the tubercle bacillus,
by special statement of “Koch’s postulates”,
establishing the pathogenic character of a
given microorganism, which had already been
adumbrated by Henle and Edwin Klebs.
About the same time Koch and his assistants
introduced sterilization by dry heat. Then,
Koch at the head of the German Cholera Com-
mission, visited Egypt and India, discovered
the cholera vibrio, its transmission by drink-
ing-water, food, and clothing, and incidentally
found the microoorganisms of Egyptian oph-
thalmia or infectious conjunctivitis, which is
the Koch-Weeks bacillus, for which results
he received a donation of 100,000 marks from
the Prussian State. Then he was appointed
professor of hygiene and bacteriology at the
University of Berlin, where his laboratories
became crowded with bright pupils from all
over the world, among whom were Gaffky,
Loeffler, Pfeiffer, Welch, and Kitasato.
At the Tenth International Medical Con-
gress, at Berlin, Koch announced his belief
that he had found a remedy for tuberculosis;
the introduction of tuberculin, his one mistake,
in that it was prematurely considered, was
hailed all over the world as an event of the.
greatest scientific moment, and honors and
felicitations of all kinds were showered upon
him. Although he himself had limited his claims
to the possible cure of early cases of phthisis,
the great hopes which had been entertained of
the remedy were not realized in time, and the
number of failures and fatal cases impaired
the confidence of the profession, but abated
little of Koch’s great reputation, especially
after discovery that tuberculin is the most re-
liable means of diagnosis. In 1891, the In-
stitute for Infectious Diseases was founded
in Berlin, and remained under his direction
until he resigned in favor of his pupil Gaffky.
While directing the institute his ideas were
applied in fighting the cholera epidemic at
Hamburg, and during this time he wrote an
important paper on water-borne epidemics,
showing how they may be largely prevented
by proper filtration. He investigated rinder-
pest in South Africa at the request of the
English government, devised a method of pre-
ventive inoculation, and made valuable studies
of Texas fever, blackwater fever, tropical ma-
laria, surra and plague. The next year he
produced his new tuberculin, and after that
investigated malaria fever in Italy. At the
London Tuberculosis Congress he announced
his view that the bacilli of bovine and human
tuberculosis, which had been separated and
studied by Theobald Smith, are not identical,
claiming that there is little danger of trans-
mission of the bovine type to man. These
views were reiterated at the Washington Con-
gress, and on both occasions aroused violent
controversy, the general trend of opinion be-
ing in favor of Koch. Next, he studied Rho-
desian red-water fever, horse-sickness, tryp-
anosomiasis, and recurrent fever in German
East Africa, and in the same year established
methods of controlling typhoid which have
been adopted almost everywhere.
Koch received the Nobel Prize after resign-
ing the directorship of the Institute of Infec-
tious Diseases and then visited Africa again at
the head of the Sleeping Sickness Commis-
sion, introducing atoxyl for the treatment of
the disease. Although he was honored by a
membership in the Prussian Academy of
Sciences and the title of Excellenz, he was not
happy in the later years of his life. Certain
changes in his domestic arrangements es-
tranged many of his friends, and subjected
him to harsh criticism, which he bore with
stoicism and dignity, but which told upon him
in the end. He died of heart failuie at the
age of 67, thus ending the life of one of the
greatest men of science that his country has
produced.
344
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
ETIOLOGY, DIAGNOSIS AND TREAT-
MENT OF PEPTIC ULCER*
George H. Lathrope, M.D.,
Member Medical Board Morristown Memorial Hos-
pital; Consulting- Physician to All Souls Hospital,
Morristown, The Dover General Hospital The
New Jersey State Hospital at Greys’tone
Park, and the New York Stock Exchange.
Newark, New Jersey
Introduction
The terms peptic and pyloric ulcer are used
here inclusively to denote both gastric and
duodenal ulcer, which in the majority of cases
occur within l1^ in. on either side of the
pylorus. Some ulcers occur fairly high on the
lesser curvature, and the English, and now
many American writers, use the term peptic
ulcei as descriptive of both groups. Some
American writers always distinguish between
gasti ic ulcei and duodenal ulcer on the ground
that theii course differs, their management
\aiies, that surgery is more commonly needed
in one than the other, and even that there may
be differences in pathogenesis. Anatomic and
physiologic considerations, however, are so
much the same as to make it reasonable to
think of the pyloric area as embracing the dis-
tal \y2 in. of the stomach and an equal por-
tion of the proximal duodenum. There seems
no reasonable justification as yet for a divid-
ing line between stomach and duodenum, with
differing indications, prognosis, and thera-
peutics on the two sides. It seems simpler
and more sensible at present to include the en-
tire area in a single conception, and the terms
“pyloric ulcer” and “peptic ulcer” will there-
fore be used interchangeably to denote the
same condition.
An exposition of pathology and symptoms
has not been attempted in this discussion, as
they are partially and, it is hoped, sufficiently
dealt with in the sections on etiology and diag-
nosis.
Etiology
I he etiology of ulcer of the stomach or
the duodenum is still one of the befogged
areas of medical controversy. Various ideas
’(Read before Warren County Medical Society
October 21, 1930.)
have been and still are current, all largely
hypothetic, and backed up only partially and
incompletely by experimental work or exact
knowledge. We know much about the physi-
ology of the stomach ; we are on the eve of
knowing more about distortions of that phvsi-
°logy ; but as to how an erosion of the mucous
membrane begins, or why in some cases it
should go on to form a chronic ulceration
which upsets the digestive economy, and too
often threatens the victim’s life, is still some-
thing of a mystery. The problem, according
to Aschoff (and in this he is followed today
by most observers), centers around the ex-
planation of 2 phenomena: (1) the primary
bieak in continuity of the mucous membrane,
i.e., the acute ulcer phase; and (2) its failure
to heal, the chronic phase.
Rehfuss has offered evidence that acute ul-
cer may be produced by extraneous toxic sub-
stances introduced into the stomach, and Bol-
ton believes that metabolic toxins can pro-
duce the same effect. Durante has shown
very definitely that trophic disturbance can
cause acute ulceration which may persist as a
chronic lesion. He concluded the report of
his experimental work thus: “***** ujcer
may be produced by any agent capable of
damaging the sympathetic nervous system (the
median splanchnic nerve in particular), as it
is on the integrity of this system, which con-
trols circulation, secretion, and profound sen-
sibility in the stomach, that the very life of
the gastric cell may be said to depend. The
theory of trophic ulcer must be taken in this
sense.” Judd, reviewing the etiology of ulcer
in the 1927 Mutter Lecture, while mentioning
Rosenow’s work, places most emphasis on the
research of Mann demonstrating in animals
the invariable development of ulcer whenever
the duodenum was sidetracked so as to keep
the biliary and pancreatic fluids away from
the pylorus ; and likewise the cure of ulcers
so produced by restoring the normal admix-
ture of gastric and duodenal juices at the py-
loiic region. Rosenow offered evidence in
191d that streptococci injected into the blood
stream may have a selective affinity for the
gastric mucosa and produce acute ulcer. In a
later publication (1916) he stated that to sup-
port the idea that gastric ulcer in man is due
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
345
commonly to a local hematogenous strepto-
coccal infection, it would be necessary to show :
first, that in such ulcers streptococci are
usually present to the exclusion of other types
of bacteria; and second, that streptococci iso-
lated from the ulcer wall, as well as those
from foci of infection in the same patient,
will produce, when injected into animals, ul-
cers of, the stomach or duodenum resembling
those in man. He then retails the experimen-
tal work by which he supports these postulates.
No one of these ideas has been substantiated
as yet by a sufficient number of other work-
ers to make it universally acceptable as the
established etiologic factor ; but there is slowly
accumulating considerable evidence that the
primary necrosis of the mucous membrane is
caused in some such manner as these various
lines of research indicate, with a preponder-
ance of evidence in favor of some form of
bacterial activity. Only recently (1928) Nickel
and Hufford have reported an exhaustive study
of the elective localization of streptococci ob-
tained from peptic ulcers, and declare their
complete agreement with Rosenow. They state
a further important conclusion, that “the over-
whelming number of patients suffering from
peptic ulcer harbor * * * septic foci”.
Given whatever causation of an area of ne-
crosis on the mucous surface of stomach or
duodenum, most observers agree that action
of the hydrochloric acid or the pepsin, on the
raw surface thus produced, plus traumatism
from peristaltic unrest, will tend to make and
keep the ulceration chronic. Whether bacterial
action can continue in the presence of the gas-
tric juice is doubtful, for only a few active
bacteria can be cultured out of the gastric con-
tents, or from a base of such ulcers postmor-
tem ; and the consistent growth of bacteria
in vitro in an acid medium equivalent to that
of the gastric secretion, has not been success-
fully accomplished.
The factors making for chronicity of an ul-
cer once begun are probably numerous. It is
quite possible that many ulcers arise and heal
spontaneously, without perhaps ever having
been recognized. The irritating quality of
the gastric juice may be the largest single fac-
tor making for chronicity; but peristaltic un-
rest, irritating foods, toxins of metabolic
origin, successive bacterial invasion, and low-
ered vitality and resisting powers on the part
of the patient, must all be taken into consider-
ation. Another factor may be that the dis-
turbance of gastric physiology which results
from the presence of an ulcer, or from con-
ditions which produced it, causes a fatigue or
depression of the local healing forces inherent
in the gastric mucosal cells. Holman stresses
the importance of fatigue, particularly a local-
ized fatigue of those cells concerned in the
pathology of the condition, and then makes
this sensible and conservative statement : “The
frequently satisfactory results of simple means
of giving rest certainly speak against the
primary dominant importance of bacteria in
the etiology, but should not blind us to their
extremely dangerous role in complicating the
condition, and where their source is in other
infected foci these should certainly be attend-
ed to.”
An important and common clinical obser-
vation is that ulcer is a condition prone to re-
lapse. It would be better perhaps to use the
word “recur” ; for it is quite likely that the
ulcer heals, and a fresh ulcer forms later on,
due to the same factors which brought about
the original ulcer and which have not been
removed. It has been a striking fact in our
own cases that several patients who have for
periods of 3-5 years shown no tendency to re-
currences, are cases in which were found very
bad tooth root infections, which were cleaned
up soon after instituting treatment. If this
observation has any etiologic significance it
tends to support the idea that bacterial activity
of some sort has to do with the inception of
ulcer.
In summarizing this question of etiology.
Nickel and Hufford say: “It is universally
agreed that the fundamental change per se in
the gastric or duodenal mucosa is impaired
nutrition in a localized area, with subsequent
necrosis, sloughing, and digestion in the in-
jured area by the corrosive action of the acid
gastric juice. The mechanic, corrosive, throm-
botic, embolic, and neurogenic factors are em-
phasized by the exponents of the different
theories.”
Conclusion. For clinical purposes, then, it
seems a fair assumption, on the basis of pres-
346
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
ent day evidence, some of which is factual,
while other is hypothetic and from analogy,
that ulcer is induced primarily by blocking of
the terminal vessels in the gastric or duodenal
mucosa, possibly due to bacterial invasion,
which thus causes a localized area of necrosis;
that this probably occurs most readily, or per-
haps only, in a patient whose general resist-
ance is lowered, and whose local resistance
also is fatigued ; that, an ulcer once establish-
ed, its chronicity is determined by the diges-
tive action of acid gastric juice, peristaltic un-
rest, and the influence of toxins from without
or within the organism, as well as other ill-
understood factors.
This offers a very practical working hypo-
thesis to the clinician ; for it leads him logi-
cally to his most important measures for
treatment, namely, physiologic rest, and the
eradication of infective foci. *
Diagnosis
There is one and only one indisputable
method of accurate diagnosis ; and that is di-
rect visualization of the ulcer by the surgeon
or pathologist at operation or at autopsy.
These gentlemen maintain a certain Presby-
terian smugness on this question of diagnosis,
because they are so sure of their position as
the final arbiters. Nevertheless, the prac-
titioner must do the best he can to determine,
as nearly as may be, an accurate diagnosis for
the patient who he hopes will come neither
to operating nor autopsy table ; and it is as-
sumed that this discussion deals with the
earlier and more benign stages of ulcer, and
not with lethal or near lethal conditions.
Prior to and apart from either of these re-
grettable procedures the nearest approach to
accuracy is that of the roentgenologic demon-
stration of a constant niche on the outline of
either stomach or duodenum. If the roentgen-
ologist is not happy in his choice of angle at
which the films are exposed, or if he is impa-
tient, or if he just does not happen, with all
*A very complete resume of the various theories
of etiology and pathogenesis of ulcer appears in
The Medical Clinics of North America for Septem-
ber 1930 — by Held and Goldbloom, of Beth Israel
Hospital, N. Y. Beyond its value as a review, how-
ever, it leads nowhere; and it is felt that the
theories outlined above are the most practical and
therefore constructive.
his care and skill, to show the ulcer in outline,
he will miss this demonstration of its presence.
But to show a niche on a single film does not
constitute a diagnosis. That evidence should
be the same on 2 or more films taken at appre-
ciable intervals. If it is present on more than
one of several films taken minutes — not sec-
onds— apart, it means something. The niche
of ulcer may be simulated on a single film, or
on successive films taken within a few sec-
onds of each other, by the vagaries of peri-
staltic action combined with an adhesion on the
peritoneal surface ; and with niches that are
not deep and pronounced this is a most con-
fusing diagnostic factor, and failure at proper
interpretation may destroy the differentiation
between ulcer and gall-bladder disease. A
constant incisura only indicates some irritative
lesion in the gastro-intestinal wall ahead of it;
and while that lesion is most commonly ulcer,
because ulcer is the common condition, yet it
may be due to cancer, or to gall-bladder dis-
ease. A 6-hour retention in the stomach ex-
presses much the same thing, and, while us-
ually due to ulcer, may be caused by other
obstructive lesions. Hyperperistalsis must be
interpreted with due regard for the physiology
of the gastro-intestinal tract, and the reasons
why such a phenomenon presents itself. Ulcer
is not its sole cause. It is an evidence either
of irritation or of obstruction.
Turning to other laboratory aids there is
but little that is helpful ; nothing that is pathog-
nomonic. Urinalysis may be dismissed with-
out comment. Blood chemistry offers no help.
The white cell count may reveal evidence of a
chronic infective process — nothing else — but it
is of importance in that a leukocytosis or poly-
nuclear increase should emphasize the need of
a search for focal infection ; and, without
either leukocytosis or polynuclear increase, an
abnormal number of immature forms of
polvnuclears is in itself an index of chronic
infection. The red cell count may demon-
strate an anemia, suggesting seepage of blood
from an ulcerated surface ; and, if it can-
not be satisfactorily accounted for otherwise,
may prove an important finding. Examination
of the stools for occult blood is valuable, and
should be a routine procedure. If care be
taken, a positive test for occult blood should
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
347
be regarded as abnormal and its significance
carefully weighed, especially if accompanied
by anemia of any appreciable degree. Blood,
occult or gross, in the gastric content, demon-
strated either in test meal or in vomitus, should
be treated skeptically, remembering that it
may be the result of traumatism. Gastric
analysis has not proved itself anything but dis-
appointing so far as the diagnosis of peptic
ulcer is concerned. Hyperacidity is not a
diagnostic finding in ulcer. Ryle has shown
that it occurs too frequently in otherwise per-
fectly normal individuals; that it occurs in
too many conditions other than ulcer ; and
that both hypo-acidity and normal acidity,
may be demonstrated in too many ulcer pa-
tients. The method is wasteful both of the
physician’s time and of the patient’s money,
and not worth in its results the time, discom-
fort, or expense to both patient and physician
that are required for its careful performance.
Lastly, we must consider the diagnostic
data obtained by the clinician himself ; and as
a matter of fact these should be the most im-
portant of all. Upon his intellectual capacity,
his ability to gather and weigh evidence, his
genius for correlation of all the facts pre-
sented by his own investigation and that of
his laboratory and x-ray helpers, depends the
welfare of his patient. He has before him a
question fundamentally of differential diag-
nosis. Periodic pain is an evidence probably
of tonic over-contraction of the gastric muscu-
lature. It may occur as a result of lesion in
the stomach or outside it. It may be due to
toxic substances such as those from excessive
use of tobacco, or from bacterial action, as in
tuberculosis and focal infections. It may be an
evidence of gall-bladder or appendix disease
quite as truly as of ulcer. All these and many
other conditions the clinician must keep in
mind, carefully gather his bits of evidence,
and evaluate them from every possible angle.
There may be a fair certainty of ulcer ; but
before it is written down and treatment be-
gun, is there reasonable assurance that it is
not an appendix, that it is not gall-bladder dis-
ease, that it is not due to excessive smoking,
that there is no chronic infection, or any other
of the conditions which may reflexly or di-
rectly give rise to gastrospasm?
The same statement applies even more forci-
bly to the symptom of hyperacidity or acid
dyspepsia. While that symptom appears fre-
quently with ulcer, it is also part of the symp-
tom complex of other disorders, and must be
regarded diagnostically with more than the
proverbial grain of salt. The need for care-
ful differential diagnosis was indicated in a
recent experience of analyzing 255 of our
own cases which presented these symptoms.
Vomiting of blood is strongly suspicious,
but may occur in cancer, blood dyscrasias, cir-
rhosis of the liver, and is said to occur in
chronic appendicitis.
Tenderness in the epigastrium may be pres-
ent in any case which exhibits periodic pain
or an excessive acid dyspepsia. Rigidity is a
sign of ulcer near perforation, or at any rate
of a near surgical condition.
Conclusions. The serviceable diagnostic
criteria may then be summarized as follows :
(1) Niche on x-ray examination.
(2) Incisura on x-ray examination.
(3) 6-hour gastric retention.
(4) Hyperperistalsis.
(5) Secondary anemia without other ex-
plainable cause.
(6) Occult blood in the stool.
(7) History of acid dyspepsia and of peri-
odic pain.
(8) Vomiting of blood.
(9) Tenderness in the epigastrium.
(10) Rigidity in the episgastrium.
(11) Exclusion of other conditions which
might present the same picture in whole or in
part.
The first and the last mentioned would ap-
pear to be the points to be especially stressed.
Diagnostic criteria individually are uncer-
tain, and only a careful balancing and weigh-
ing of all acquirable evidence will bring satis-
factory diagnostic results. In the limited time
at our disposal the high spots only of this sub-
ject can be touched. No effort at refinement of
detail can be attempted. The purpose of this
paper is served if it but indicates to the clini-
cian that it is his job to diagnose ulcer; that
he cannot sidestep that task nor safely or
fairly shift the burden to the shoulders of the
roentgenologist or the surgeon. Were diag-
nosis easy we would not be discussing it. It is
348
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
the type of problem which makes medicine in-
teresting and attracts men of intellect to the
ranks of the profession. Dean Quinn, in a
recent number of the Yale Review, concludes
his essay with this sentence which is a propos
of our own discussion : “The difficulties them-
selves make the pursuit attractive, for its un-
certainties arise from the very qualities that
make it fascinating.” Tire positive Wasser-
rnann, the Widal reaction, the finding of ma-
larial plasmodia in the blood, are examples of
a few — and they are very few — of the pathog-
nomonic types of diagnosis. Were all medi-
cal diagnosis on this basis it might be turned
over to technicians. The fault of clinicians
is that they are too often looking for short
cuts to save both time and intellectual energy.
This is a lazy trait and does not belong to good
medical practice. The work of diagnosis in
ulcer rests with the clinician and can neither
be evaded nor imposed on the technical worker
in laboratories and operating room. It must
be assumed by the man to whom it belongs,
and whether he will or no, the clinician, if he
be honest, must accept his responsibilities, ad-
mit if need be his own ignorance, but not try
to shirk a task primarily his own.
Treatment
Distinctions between the management of
gastric ulcer on the one hand and duodenal
ulcer on the other have been attempted, and
more or less satisfactorily maintained, by var-
ious writers. There seems to have been work-
ed out, however, no clear cut indication either
way, and it is probably safest to handle all
cases, in the beginning at least, according to
the same definite routine. The attending
physician will discover sooner or later that
some departure from the routine must be
made in a fair number of his cases, dependent
on individual peculiarities, requirements, or
reactions.
The essence of medical treatment may be
summed up in the one word — rest. This means
primarily and always rest for the ulcerated
organ ; for an era continuously in motion
and constantly called upon to work or func-
tion at full speed is not in an ideal condition
for reparative work. Rest is essential to save
time and bring about the best results, or even
any results whatever. Peristalsis in the
stomach can no more be made to cease en-
tirely than can the cardiac beat ; but it may
be reduced to a distinct minimum, first, by
giving the stomach as little work to do as pos-
sible, and, second, by putting the entire body
at rest, and so quieting down to the lowest
ebb vascular and nervous tension in stomach
and intestine.
To this end the first requisite is rest in
bed for 1, 2, or 3 weeks according to in-
dividual need; and the second a carefully
regulated diet, so arranged that for a few days
a bare sufficiency is allowed to keep body and
soul together. This diet should be simple
and given at frequent intervals; for if any
amount of hunger contraction is allowed to
develop it will aggravate in the gastric wall
the very condition of muscular tension, to-
gether with increased vascularity and activity,
which it is so requisite to keep at a low level.
Therefore, a temporary even though brief
complete starvation is not desirable.
Lenhartz, Sippey, or Von Leube dietaries
may be followed exactly or with modifications
arranged according to the fancy and exper-
ience of the physician. These plans are all
based on the reasoning outlined above; and of
a dozen different physicians treating ulcer, no
2 may work out the same detail, and yet all
will secure equally good results. Indeed, the
same man may treat a dozen different cases
with a dozen variations of his scheme. Milk
and white of egg constitute the bulk of the
diet for the early days ; then whole eggs are
added, and gradually cereal gruels, bread and
butter, cream soups, cream cheese, pureed
vegetables, etc. By the end of 3 or 4 weeks
the patient should be on a diet which in qual-
ity and quantity will suffice him daily for the
ensuing year.
It will be noted on inspection of these var-
ious dietaries that the essential element is ex-
clusion of anything which cannot be readily
broken up in the stomach or is not easily
soluble. There is no roughage or indigestible
residue. This is for 2 reasons : first, that by
giving things easy of digestion the stomach has
less work to do ; second, that scratchy foods
may unduly irritate or mechanically injure the
gastric mucosa. The second is a poor reason,
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
349
but the first is probably good — to save the
stomach from being over-worked and its re-
sistance therefore lowered.
So much for dietetic principles. What of
drugs? They play a minor but important role.
Alkalies alone or combined with bismuth may
be given before or after every feeding or in
relation to alternate feedings only. A powder
of heavy oxide of magnesia gr. 10, bismuth
subnitrate gr. 5, and saccharum lactis gr. 5, 3
or 4 times a day is very useful. It is usually
given after meals, but one sometimes finds the
patient likes it better when given just before
the feeding. This powder apparently controls
the sour taste and heart-burn, alleviates the
pain to a considerable extent, checks formation
of gas, and keeps the bowels open. Tincture
belladonna may be given in 5 or 10 gtt. dose
with each powder, and probably does much to
relax the gastrospasm which is perhaps the
great pain producing factor in ulcer. There is
little or no place for any other drugs in the
routine handling of these cases. Some pa-
tients who are definitely hypothyroid are slow
in healing ulcer, and their reparative processes
will be hastened by judicious feeding of thy-
roid up to their metabolic needs. Alcohol is a
distinct irritant to an ulcerated mucosa and
must be rigidly excluded. Tobacco, through
the effect of nicotin on the vagus, excites gas-
trospasm and is best discarded for the time
being.
An ice bag to the epigastrium may alleviate
pain and tenderness. Some patients find it
soothing. Others prefer not to be bothered
with it.
Rest in bed with bathroom privileges should
be enforced for at least 2 weeks, or until pain
has disappeared. This is especially requisite
•during the first week when the intake is low,
running from 1000 to 1500 calories, and is
not sufficient to admit of any unnecessary ac-
tivity without dangerous loss of vitality and
great over-draft on reserve strength.
Again, and it cannot be insisted on too
often, bodily rest will secure greater rest for
the stomach, and the more completely the
stomach is quieted the sooner and more readily
will the diseased area be restored to normal.
Such is the general scheme of medical care
of ulcer, and it will suffice for the largest num-
ber of patients. It is highly probable that,
treated in this manner, the ulcer which reacts
favorably is well started on its way to healing
in 10 days or 2 weeks ; certainly deep niches
into which the end of a lead pencil might be
thrust in. or more show nothing to mark
their site when filmed at the end of 2 or 3
months, and the smaller erosions perhaps heal
in a very short time, almost comparable to the
aphthous ulcers one sees in the mouth.
Confusion comes occasionally in the second
or third week of treatment when the patient
begins to complain of returning pain. Inquiry
may show that it is rather different from the
former pain — not definitely periodic, but
sharper in character, and located lower in the
abdomen. This is probably due to the mag-
nesia, which may be cut down or stopped for
24-48 hours, when the pain disappears. Re-
currence of real hunger pain, as the patient’s
diet is more extended, is not uncommon. It is
probably due to slow healing of the ulcer, or
to recrudescence, and is simply met by a re-
turn to first principles, and working the diet
up again from the beginning. Inability to
handle milk or eggs sometimes causes trouble.
Substitution of malted milk, cocoa, or butter-
milk will usually relieve the situation. If the
bowels do not keep satisfactorily open, a daily
enema is used.
There are certain intractable cases, and
some of the cases with hemorrhage, which
are best handled by passing a duodenal tube
and leaving it in situ for a period of 1-3
weeks, feeding peptonized milk and eggs
through the tube at 2 hr. intervals. A longer
period in bed is necessary for this type of
patient.
And finally there is the case which relapses
persistently ; or shows no tendency whatever
to heal ; or which bleeds persistently ; and for
this the answer must be supplied by the sur-
geon. Perforation and definite organic ob-
struction at the pylorus are, of course, sur-
gical as soon as diagnosed.
How to prevent recurrence? No one knows
the true answer to this question but a care-
fully restricted diet for 1 or 2 years is essen-
350
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
tial, and as soon as the patient is around and
on his feet after the preliminary rest period,
all infective foci must be searched out and so
far as possible eradicated. If there is anything
in the theory of bacterial influence in this dis-
ease; if there is any reasonable analogy from
other conditions f amiliarily associated with
focal infection ; a house-cleaning of bad teeth,
sinuses, tonsils, etc., is in order for every pa-
tient who has had ulcer.
ANNUAL CONVENTION
Medical Society of New Jersey
Asbury Park, June 3*5
Are you preparing to attend the 165th Annual
Meeting of your State Society?
We hope to publish, as usual, in the May Jour-
nal, a complete program. Meanwhile, accept our
assurance that it will be attractive, and make your
reservation for self and family — for the Woman’s
Auxiliary is making enticing plans for your wife
or nearest female relative — at the Berkeley-Car-
teret Hotel.
Our confreres in Monmouth County, collectively
and individually, are striving to make the Asbury
Park convention a big success. Give them your loyal
support.
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
351
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J.
Entered at the post office at Orange, N. J., as second-class matter
PUBLICATION COMMITTEE
HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J.
EDITOR:
HENRY O. REIK, M.D., F.A.C.S., Vermont Apartments, Atlantic City, N. J.
Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to
receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fact.
NOTE. — The transaction of business will be expedited, and prompt attention secured if:
All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to
The Editor, Atlantic City, N. J. t
All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements,
or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication
Committee, (address above), Newark, N. J.
DOCTORS ARE “EASY MARKS”!
At the very moment when we were de-
nouncing the American Tobacco Company for
broadcasting the statement that more than 20,-
000 physicians had signed endorsements of
Lucky Strike cigarettes ; and while we were
expressing doubt that so large a number could
have “fallen for” the method employed to se-
cure their signatures — and doubt whether any
ever signed the phrase alleged (that Luckies
.are less irritant to the throat than other cigar-
ettes) ; some of our own state society mem-
bers were doing their level best to prove that
even physicians of considerable experience
with public affairs can be induced to sign most
anything.
The Atlantic City Daily Press, of February
2, 1931, carried a quarter-page advertisement
of a certain cigar, and the central feature of
that “ad” is a letter signed by one of the best
known city health officers of the state. A few
days later the Newark Evening News con-
tained a similar advertisement with a similarly
featured letter signed by another equally well
known city health officer. These special let-
ter advertisements have appeared in other
newspapers inside and outside of this state,
and each of them so far observed says that
almost 57 varieties of health officers have
furnished the tobacco company with such let-
ters. The advertisements referred to not only
publish the health officer’s letter but they make
the most of his official position by displaying
in large type headlines, his name, title and
location ; disclosing very clearly what the ad-
vertising company was after and to what it
attributed any value his testimonial might
have.
The letters, themselves, are worth reading
by any one interested in advertising methods
or in medical and business ethics. In the first
place it will be noted that each letter contains
a clause — we suspect dictated by the com-
pany’s agent — designed to relieve the com-
pany of any responsibility for publishing the
signer’s opinion ; “any use you may care to
make of this letter will be agreeable to me”,
is a phrase that must have been supplied by
the company, for it could not possibly have
originated spontaneously in the minds of more
than 50 letter writers in different parts of the
country. That last sentence in each letter —
even though it is varied slightly — not only
justifies the above mentioned suspicion; it
even arouses our suspicions as to authorship
of other portions of those letters. Did the
doctors really write the letters, or did they
merely sign — on the line — letters presented to
them? Not that the answer matters; they
made themselves responsible for the letters, in
either event, but an answer might contribute
something toward a determination of just how
“easy” they were.
It is difficult to assume that these health
officers independently constructed and volun-
tarily submitted the letters to the cigar com-
pany or its advertising agency, but let tis try
to adopt that assumption and read their let-
352
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
ters in that light. The naivete exhibited — of
purpose and phraseology — will certainly en-
tertain you. Each congratulates the company
upon its noble health crusade or commends
the company for conducting a war against pos-
sible infection from spit. One such letter we
have seen actually becomes rather slobbery
in its effusive endorsement. The combination
of health officers and cigar manufacturers
threatens to annihilate the “friends of spit’’,
whoever they may be. Well, a crusade by a
tobacco selling company against spit and spit-
ting would surely be another noble experi-
ment, and would possibly be deserving of com-
mendation by those doctors were it not for
the fact that a moron confronted by the con-
ditions existing when the letters were signed
could scarcely have avoided noting that the
company was not half so much interested in
protecting the health of smokers as in having
the letters convey to the public the impression
that all other cigars than this one brand are
manufactured in a filthy manner. That is the
proposition those men actually signed ; that is
the object of the advertisements in which their
letters are embodied. Is it possible they were
so simple minded as to suspect no ulterior
purpose — so innocent as to believe this cigar
advertising campaign to be a public health
crusade ?
The following Associated Press item ap-
peared in newspapers all over the United
States on February 16:
•
"Cigarette Advertising Assailed. Washington,
February 15, (AP). — In an editorial in its weekly
clip sheet attacking the ‘tobacco companies’, the
Methodist Episcopal Board of Temperance con-
demned the creation of an ‘impression that the
use of cigarettes by youftg women is socially nec-
essary’, and the testimony ‘bought’ from physi-
cians and others concerning the effects of tobacco.’’
We submit that this is not a nice thing to
have said about our profession ; especially as
we are compelled to admit that technically the
charge is true. The physicians who signed
cigarette or cigar testimonials probably did
not realize that they were being bought, but
the company probably felt it was paving for
the act when delivering to the signers a car-
ton of cigarettes or a few cigars ; incidentally,
a pitifully small price considering the use
made of the testimonials.
THE PHYSICIAN AN IDEALIST
At a time when the medical profession is
being “knocked” on every side and the honest
physician hesitates to open any monthly
magazine lest he shall be greeted by another
printed attack upon himself or his confreres,
it is interesting to run across words of praise
from an unexpected source. The Bulletin of
the Medical and Chirurgical Faculty of Mary-
land (the Maryland State Medical Society)
for March contained a short article setting
forth the views of a distinguished trainer of
college athletes, Knute Rockne, who has had
contact with thousands of young men at the
age when they are making choice of a career.
As stated bv the Bulletin, his observations and
bis philosophy are not only refreshing but
they should carry weight.
In tracing the career of one of his former
gridiron stars, who had elected to study medi-
cine, he said : “No other profession is nearly
so exacting. I have been wondering what
makes young men want to go into the prac-
tice of medicine with all its grief, endless
hours, long preparation and what not. It has
been my observation that the good doctors
have a sort of spark in their eyes, whereas
many other professions interest men from the?
standpoint of monetary reward, easy liveli-
hood, soft berth, prestige or a stepping-stone
to something else. This can never be said of
medicine. Medicine apparently is all-absorb-
ing and occupies all of a man’s wakeful mo-
ments, and even some of the others. I have
tried to analyze some successful doctors and
I find that all of them have personality, abil-
ity, honesty, capacity for work, a burning
zeal toward perfection in their chosen
specialty, and intense responsibility regarding
the human lives they are taking care of.”
STATE MEDICINE
In the February Journal we published an
interesting original article by Dr. Haigh, of
Worcester, Massachusetts, author of the Bill
presented to the legislature of that state pro-
posing the establishment of state medicine on
a plan modeled from that in use by the United
States Navy; an article in which Dr. Haigh
succinctly explains why he thinks some form
April, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
353
of state control of medical practice is inevit-
able and why he considers the Navy Medical
Corps a suitable model for adoption.
In the March Journal we presented, in the
course of a “travel talk”, a summary of the
British National Health Insurance Law, and
our impressions with respect to its working,
together with an explanation of a new propo-
sition recently made by the British Medical
Association for extension of that law — state
medicine in its complete form — to the entire
population.
This month, again in the “travel” article,
we have described what is so far known of
the new law which took effect in France so
recently as July last. Also, in this month’s
Collateral Reading Department, we have told
what little accurate information we have con-
cerning Soviet control of medicine in Russia.
We have in hand several documents from
Canadian provinces yet to he abstracted for
publication, and we hope to digest that for our
readers next month.
As stated elsewhere, and upon other
occasions, the object in publishing this ma-
terial is that members of this society may
have ready access to facts concerning the ex-
istence of and progress being made by state
medicine. Within the past month, a Bill has
been introduced into the New York State
Legislature that would provide for com-
pulsory health, accident, life and unemploy-
ment insurance and old age pensions ; an ex-
pansive combination. The day is certain to
come when New Jersey will have such legisla-
tion to consider. Let us be well informed and
prepared to meet the situation in a proper
manner.
PERSONAL INTEREST AND
ACTIVITY
Spring is in the air and the time approaches
when state and national medical associations
command attention. Throughout the autumn
and winter months county societies have held
sway and the Journal has not only published
accurate reports of their proceedings but has
served as an additional medium for providing
information — scientific and general — concern-
ing matters of special import to medical prac-
titioners. The county society is the basic unit
of medical organization. The state society
constitutes the forum where all the county
representatives may meet for conference with
a view to effecting concerted, unified action
upon important problems. During the past,
or rapidly passing, year our members have
been supplied with a vast amount of informa-
tion relating to economic problems with which
organized medicine at present has to deal. In
all probability, some of those questions will be
discussed, possibly acted upon, at the state so-
ciety meeting in June. Possibly because that
thought was in mind we were impressed by an
editorial in the Ohio State Medical Journal
for November 1930, and we quote it for your
consideration :
“Frequent inventories are advocated by
leaders in industry and business as quite nec-
essary to the continued life and well-being of
any business ; as a practical method of keep-
ing the concern economically sound.
The same procedure might well be followed
by members of the medical profession, de-
clares the Bulletin of the Medical Society of
Milwaukee County (Wis.), to determine, if
possible, to what extent each member may be
responsible for some of the conditions which
now exist in the medical field.
The Milwaukee Bulletin suggests that each
physician ask himself the following questions
in attempting to analyze just how much he
has, or has not, contributed to his profession
and to organized medicine :
(1) Have I cooperated with my fellow
practitioners as I should, or. do I criticize them
when the opportunity presents itself ?
(2) Flave I given serious thought to the
activities of the County Medical Society, and
organized medicine as a whole?
(3) Have I offered a constructive thought
in the cause of medicine, or do I resort to
carping and useless criticism?
(4) Have I taken proper interest in pub-
lic health and preventive medicine?
(5) Flave I cultivated the vision which
embraces public welfare and sees beyond the
present, and includes the possibilities of the
future?”
354
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
Special Article
MEDICAL TRAVEL TALK
A Physician’s Vacation in Ireland, England
and France
Henry O. Reik, M.D.,
(Continued from March Journal)
Most of our journeying through Ireland,
Wales and Northern England had been ac-
companied by cool and rainy weather, but in
London we encountered a heat wave, and we
sought relief on a terrifically hot day, August
29, by proceeding onward to Paris. The
Golden Arrow Express, which has been op-
erating between London and Paris, by way of
Dover-Calais, with a special boat service, for
the past 3 years, is about “the last word” in
luxury, speed and comfort. Americans are
accustomed to boast of their own railroads
and special trains but we could profit by an
honest appraisal of English, French and Ger-
man railroads and by adoption of their best
features. In general, our service compares fa-
vorably with that of Europe, but in some re-
spects Europe leads us — and that is particu-
larly true in relation to comfort. The Golden
Arrow (Fleche d’Or, in French) just re-
ferred to, the Oriental Express from Paris
through to Constantinople, and the new Ger-
man-equipped train that starts in Holland, at
Rotterdam, and runs down through France
to Switzerland and thence eastward, are all
superior in beauty of construction, luxurious
equipment and travel comforts, to any trains
in the United States. Some of you may be
surprised to learn that we no longer hold even
the speed record. That is a record which we
need not worry over, but as we boast of our
speed in most things it seems odd that this
particular blue ribbon should have been al-
lowed to pass along to others ; yet, the fastest
train in the world is said to be the “rapide”
from Paris to Bordeaux, and the longest dis-
tance nonstop run (393 miles) is made by the
Flying Scotsman connecting London with
Edinburgh in 8j4 hours.
On this particular occasion we lingered in
Paris but a few days — only long enough to
arrange for an autobus trip through Brittany
— and September 8 found us at Vannes ready
to start upon a tour of that quaint portion of
France. On the way to Vannes we had paid
short visits to Rennes and Josselin; the lat-
ter an ideal place for acquiring the proper
“background”, the proper “state of mind”,
for absorbing medieval history. To reach
Josselin we had to make use of both modern
and ancient types of transportation: a fast
express from Paris to Rennes, passing through
the beautiful “granary of France” ; a local,
“way train” (omnibus, as the French call it)
to Ploermel ; a typical “Toonerville jerk-
water”, drawn by a small, wood-burning en-
gine, upon a narrow guage track, traversing a
beautifully forested country; and, finally, on
our own feet from the station, situated upon
the edge of the old fortified town, to the hotel
about an eighth of a mile away, and all of it
up-hill, in the center of the town, facing the
old cathedral, close beside the castle. But,
having arrived, we felt repaid for all the
trouble and exertion ; we had been miracu-
lously, as it were, lifted out of modernity and
set down in the midst of medievalism.
Our guide book furnished the information
that: “The superb castle of Josselin, compar-
able to nothing else so much as Warwick
Castle, in England, was founded about the
year 1008, on a site very defensible and very
holy; for more than 3 centuries it was a pil-
grimage shrine of great sanctity and renown.”
We found the castle still an imposing and
fascinating institution, whether viewed from
across the river or from inside its enclosure,
and the town is still the focal point of great
religious pilgrimages; one of the most in-
teresting being those curiously picturesque
“Breton Pardons” which have been held an-
nually, unchanged in character, for several
hundred years.
Clara Laughlin describes such celebrations,
as follows: “Usually a pardon has 3 phases:
the eve ; the religious ceremony ; and the
merrymaking. The eve is devoted to confes-
sion and prayer, the pilgrims flocking in from
every direction. They come bareheaded, bare-
footed, and usually fasting, followed by crowds
of the lame, the halt, and the blind. There is
a sermon, drinking at the holy well or other
miraculous source, and a torchlight proces-
sion. Next day there is the ceremony which
is the distinctive feature of that special par-
don— the blessing of the sea, of the boats, of
the cattle, or whatever it may be — followed by
the procession wherein every one wears the
rich, picturesque costumes that have been
handed down for generations and are kept
stored in old carved chests, except on such
occasions as these. And in the afternoon
there is a fair, followed by dancing and drink-
ing and courting.”
We were not so fortunate as to be there on
Josselin’s greatest feast day but a similar
event of lesser importance was held on the
Sunday morning succeeding to our arrival on
Saturday evening and we had full opportunity
to enjoy our first observation of the quaint
April, 1531
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
355
dress and customs of the Bretons. Armed
with Kodak and Filmo, we began at once to
acquire snapshots and movies of people, events
and dress entirely new to our experience.
Of the castle much might be said but we
must be content to locate it in your memory
cells by recalling some historic events with
which it was connected. It was from here
that Jean de Beaumanoir issued his challenge
to the English which resulted in the famous
Battle of Thirty — 30 knights on each side to
meet on a certain Saturday in March 1351
and settle their disputes by mortal combat.
The opposing forces met between Ploermel
and Josselin, at a point still marked by a cross
and pyramid, and of the 30 Bretons only 3
Avere slain, while the English suffered a loss
of 12 on the field and those left alive had to
beg for quarter and accept imprisonment in
the castle at Josselin. The glory was all to
Beaumanoir, but he was seriously wounded
and it was not long thereafter when the great
Olivier de Clisson married his widow and be-
came master of this castle, reigning there until
1407 and his remains resting now in the
neighboring church. “His son-in-law and suc-
cessor began the transformation of the for-
tress into the most elegant residence in all
Brittany. And through the courtesy of the
widowed chatelaine, the Duchesse de Rohan,
mother of the little Duke, we are permitted
to visit the castle. A fine old servitor, burst-
ing with pride in the great lineage and the true
noblesse of the family he is attached to,
shows us the imposing dining-room with the
great equestrian statue of Olivier de Clisson,
done by Fremiet; the salon, with its superb
mantelpiece ; the library, with the table where-
on the edict of Nantes was signed. The rever-
ent guide will show us a photograph of the late
Duke, killed in the Great War; and perhaps
one of the young lad who now bears the title.
It may be that we shall catch a glimpse of the
duchess, in her garden, writing letters or read-
ing. (We did see her, quite by accident, Sun-
day, September 7, in the morning sitting in
the shade of a tree knitting, and in the after-
noon leaving the grounds for a drive.) Her
mother-in-law, who died in the early part of
this year wherein I write, was a great lady of
many distinctions; her salon in Paris was one
of the most distinguished, of recent years, and
her ardent interest in the arts is carried on by
her daughter, Princess Murat, whose little art
exhibition and tea room you have probably
visited in Paris — on the Ouai d'Horloge and
Place Dauphine, where Manon Roland grew
no. Few of the great old feudal names of
France are more familiar in American and
English ears than that of Rohan.”
With the kindly aid of the hotel proprie-
tress— who would not permit an imposition
upon her guests, but insisted on the garage
man fixing a fair fee (considerably less than
his first named price) for the trip — we were
driven Sunday afternoon, in an ancient Ford
car much worse worn than the Eleventh Cen-
tury Castle, 20 miles to Vannes where our real
Brittany trip was to commence next morning.
But, in that glorious country one is constantly
meeting surprises, and that Sunday afternoon
we arrived in Vannes just in time to witness
its annual festival and church parade in honor
of St. Vincent ; an impressive eA^ent which Ave
were fortunate enough to record on the film
of our small moving picture camera.
It would take up too much space to tell you
all the joys of our trip through Brittany, joys
1. Menhirs — Ancient Memorial Stones at Carnac.
356
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
about which we have reminisced many times
since and of which we do not tire talking; so,
we shall have to confine our ravings here to
the “high spots”, after expressing a general
summary in the single statement that any
traveler can find entertainment, instruction
and pleasure in that arcadian area. The arche-
ologist, the historian, the antiquarian, the
humanitarian, or just the plain tourist, will
secure incentive for research and happiness
in his findings. The Bretons are a simple,
honest folk who learned centuries ago a satis-
factory philosophy of life and they do not
disturb themselves today to chase after false
gods. Just one example will illustrate our
meaning.
Brittany (Bretagne, in French) is that sec-
tion of France which projects into the Atlantic
Ocean, in the form of a peninsula, from the
northwestern corner of the country, with the
English Channel bathing its northern shore
and the Bay of Biscay on the south. Some of
you who served in the A. E. F. will re-
member it well because of having disembarked
or reembarked at the port of Brest ; and if
you spent any time in the “rest camp” of Pon-
tanezan Barracks just outside that city you
will recall that because of the geographic lo-
cation it rains there during some portion of
nearly every day— no matter which way the
wind blows. France is divided into, or is
composed of, Departments, just as our own
nation is composed of States. Bretagne is the
ancient name for that portion of French ter-
ritory which comprises present political depart-
ments of Finistere, Morbihan and the Cotes-
du-Nord. The total area of Brittany is ap-
proximately that of our state — New Jersey—
and the city of Brest, on the extreme western
boundary, is less than 500 miles from Paris.
Now, remember that Paris has been for
many centuries the fashion center of the
world, and that the great mass of so-called
civilised people of Europe, Asia, Africa,
North and South America follow the dictates
of the Parisian dressmakers and milliners ;
and yet, Brittany — French to the core, and
located at the very door of Paris — has re-
mained through all these centuries unaffected
by the changing styles in dress. When
“dressed up" the men wear black velvet coats
ornamented with silver buttons, knee breeches,
long stockings, silver-buckled shoes, and flat
derby hats with long silk ribbon streamers
hanging down their backs. The women,
too, still adorn themselves in the ancient cos-
tumes of black silk dress and starched white
linen caps ; and it is said that if familiar with
the variations in shape and form of these caps
you can tell from what portion of Brittany —
even from what parish — the wearer comes.
How sensible ! Costumes that meet all the
essential requirements: comfort, beauty, util-
ity, economy. Clothes are worn so long as
they remain presentable ; not cast aside be-
cause some arbiter of fashion has decreed a
change ; and the fascinating linen or lace caps
are washed and ironed and utilized for an in-
definite period of time, instead of being
thrown away because the seasonal calendar
lias moved from spring to summer. In our
opinion they show more sense than those of
us who deem it necessary to change hats and
dresses as rapidly as new styles can be de-
\ ised.
Do not imagine that because these people
adhere to the old style costumes they are
“backward” in all respects. You will find that
they live well, know how to use telephones,
radios and automobiles, make use of modern
machinery, and are fully awake in the trans-
action of business. They simply follow the
excellent advice given bv St. Paul — “Try all
things, and hold fast to that which is good.”
We sincerely wish our own people would
emulate the example. And, if you doubt
whether a people living so simply can still
produce virile physical specimens and gigan-
tic intellects, remind yourselves that Foch and
Clemenceau both belonged to Finistere and
were duly proud of the fact.
On the circular tour we kept close to the
coast-line so as to observe the world-famous
sardine fishery ports on the south shore, the
rugged, x'ock-bound, western shore, and the
summer resorts and bathing beaches strung
along the north coast all the way to Mont St.
Michel ; running inland occasionally to visit
the renowned cathedrals and “calvaries”, some
of which date back to the eleventh, tenth and
even the eighth century. Among the many
curiosities and artistic monuments encounter-
ed were the menhirs (Fig. 1.) (tall single
stones) and dolmens (huge, flat, table-like ar-
rangements) to be seen on the first day at
Carnac ; acres of otherwise barren land cov-
ered by stones (some of enormous size), more
or less regularly distributed, as if this may
have been an ancient tribal burying ground.
Of prehistoric origin, these orderly collections
of monoliths have been discovered in various
parts of the world and we had on this very
trip already seen similar specimens in Ire-
land.
Concarneau and Douarnenez are the chief
French ports for collection, canning and dis-
tribution of sardines, and we had the good
fortune to arrive at each port just as the
fishing fleet was coming home — one of the
most picturesque scenes imaginable. The boats
are not unlike our own fishing smacks as to
size and shape, carrying 1 or 2 masts and
April, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
357
sometimes equipped with gasoline engines, but
the appearance of the fleet is quite distinctive
and far more beautiful because of the colored
sails and nets. The net used for sardines is
naturally of very small mesh, and it is colored
sky blue to match the deep sea water, ren-
dering it less easily distinguishable when im-
mersed, and thus to fool the fish. The sails
are stained by a coating of ochre dissolved, or
suspended, in gasoline ; the sail-cloth being
spread upon the ground, a bucket of paint is
sloshed upon it and spread over the surface
rapidly by a workman with the aid of a broom ;
the oily mixture soaks into the canvas and the
excess of oil evaporates, leaving its stain. The
result is sails that vary in color from light or-
ange to red-brown, and when the boats come
will further recall, an Italian salvage crew
was successful in locating the sunken gold
and its divers had so far advanced the work
of rescuing the money as to be hauling up
the safe in which it was deposited, when a
new storm intervened, destroyed all the care-
fully developed plans and works, and drove
them from the scene; leaving the golden for-
tune still somewhere in Davy Jones’ locker.
We were, naturally, greatly interested in read-
ing about that storm because it occurred only
a week after our visit to that coast. The ter-
rible damage done by such storms, the terrific
loss of life they impose upon the fishing fleet,
and the sorrows inflicted upon the women and
children of fishermen's families, were forcibly
brought to our attention at the time. At
2. Sardine Fleet at anchor at Douarnenez.
into harbor with nets hanging from the masts
and booms to dry, and sails spread with a
background of sky and the setting sun, a
picture is produced that will long be remem-
bered.
From Quimper we made a side trip to
Pointe-du-Raz, a wild, rocky promontory of
the western coast which is the bane of all
sailors and deep sea fishermen compelled to
navigate that section of the Atlantic Ocean.
As a means of locating it for you, we may re-
mind you that it was in this vicinity that the
British ship sank, during the World War,
with $5,000,000 in gold coin locked in her
coffers ; and, also, that it was at a lighthouse
upon one of the many dangerous rock islands
off this coast that the lightkeeper and his as-
sistant were practically marooned for 60 days
in the winter of 1929-30 because continuous
stormy weather prevented any boats approach-
ing the spot with supplies. Last year, you
Douarnenez we had commented upon, and
taken pictures of, the womenfolk — some with
babes in arms and older children playing
around them — sitting in groups on the piers,
industriously engaged in knitting and gossip
while awaiting return of their husbands and
lovers with the sardine fleet. One week later
a terrific storm suddenly arose, demolished a
score of boats upon the rocks and took a
heavy toll of human lives. We could men-
tally picture those same groups of women and
children weeping, pathetically scanning the
horizon for signs of their particular boats,
praying for the return of husbands, lovers
and fathers who would never be seen again
upon this earth ; and memory reverted to that
touching poem — “For men must work and
women must weep."
The castles, cathedrals, religious monuments
and ceremonies to be visited or witnessed on
such a tour are numerous and of great inter-
358
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
est. The records of historic characters beset
one on every hand. At Saint-Malo we slept
and ate in a hotel one section of which was
once the home of Chateaubriand. At Treguier
we could pay our respects to the birth-place
of Ernest Renan and inspect the room where
he wrote some parts of his Life of Jesus; and
an excellent statue of him stands today in the
public square.
Returned to Paris, we made it our business
to inquire into the new National Health In-
surance Law which had just become effective
on July first. Because the law is so new and
only beginning to come into effect, we cannot
make for you an analysis of conditions com-
parable to that we made last month for Eng-
land. We can only present at this time a
brief abstract of the French law, setting forth
the main features of interest.
In France, even more markedly than in
England, the government has been for the
past 20 years under control of the labor party
or of political parties having a strong social-
istic leaning, and the very natural effort to
enact legislation of this character has pro-
gressed slowly but steadily until the law
reached its present form. Also, in France as
in England, the medical profession has fought
an obstinate, losing battle. Although the law,
as finally promulgated, was modified at the
behest of the profession, it is by no means
satisfactory and there is much complaining
on the part of practicing physicians and very
little evidence as yet of an inclination to co-
operate or even to submit gracefully. In ad-
dition to the orthodox form of organization
for scientific discussions, the medical profes-
sion in France is organized into “syndicats”
— on a basis similar to labor unions — for deal-
ing with the government and with economic
problems in general. In consequence, it is
the Syndicats Medicate , rather than the
Academy of Medicine, that engage in the con-
troversy and that enter into contract for medi-
cal service to those insured under the health
law, or — Loi sur les Assurances Sociales.
The insurance law is applied compulsorily
to all employees, of both sexes, less than 60
years of age who earn not more than $600
per annum ; to any employee having 1 depend-
ent child and whose salary does not exceed
$680 — or $800 if living in a city of more than
200,000 inhabitants; to any employee having
2 dependent children, and whose salary does
not exceed $760 — or $880 if in a city of more
than 200,000 population ; to any employee hav-
ing 3 or more dependent children, whose in-
come does not surpass $1000 — without regard
to distinction of locality. Such insurance is
available to, but not compulsory to, children
who perform salaried work not forbidden by
law ; children who work at home without spe-
cific salary but for the benefit of the family ;
and, all members of the family of an agricul-
tural worker so long as they work and live with
him without receiving remuneration in money.
In order to become compulsorily insured it is
necessary to be salaried. The earning capac-
ity of the optionally insured, with reference
to insurability, is measured by the same scale
as given for the compulsory classes.
The insured person chooses his assessment
according to the benefits he wishes to obtain,
but this may not exceed 10% of his annual
salary nor be less than $9.60 per annum ex-
cept where he desires only to cover the old
age pension provision, when the low figure is
$4.80 a year. The insurance fund is used to
provide for medical attention during illness,
for absence from work on account of disa-
bility resulting from sickness, for a maternity
period commencing 6 weeks prior to delivery
and continuing until the mother is restored
to normal health, and, for old age pensions
- — health benefits terminating and pensions be-
ginning at the age of 60. There is special
provision for optional insurance of non-
salaried wives of compulsorily insured men,
and for women who may become widowed or
divorced. There are also special rulings ap-
plicable to veterans of the World War, with
special reference to other aid they may be
receiving in the nature of medical care or
disability pensions ; in other words, the “law
of social insurance” is coordinated with pre-
viously enacted laws for medical assistance,
maternity aid, free service to ex-soldiers and
pensions.
Sickness insurance covers all forms of ill-
ness— without distinction between accidents
and so-called natural causes — surgical opera-
tions, dentistry, and even care at thermal
baths and “spas” when considered indispens-
able. If the patient is to be treated at home,
he has “freedom of choice of doctor, surgeon,
specialist, dentist, druggist or midwife, under
the sole condition that the attendant selected
shall be properly qualified”. The patient who
must be hospitalized has free choice of the
institution he will enter but thereafter is sub-
ject to the qualified members of the staff of
that establishment. All legally qualified prac-
titioners of medicine in France may enroll for
insurance practice but no physician is com-
pelled to accept such service, save in so far
as common decency would dictate in cases of
emergency. As in Great Britain, negotiations
between the insured, the physicians and hos-
pitals, and the government are carried on
chiefly through insurance companies ; the in-
sured selecting the “association” with which
he desires to be affiliated, with the sole limita-
April, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
359
tion that it must be an association doing busi-
ness in the local section or department where
he is employed ; and, such an association may
be formed by spontaneous grouping of in-
sured persons. There is a council of admin-
istration to supervise the insurance associa-
tions, composed of 18 members, of whom at
least 2 must be physicians elected from a list
submitted by the medical profession*. General
control of the insurance plan is vested in the
Minister of Labor, with certain definite re-
lationships to the Minister of Finance.
Elaborate machinery is proposed for
recording and checking reports of cases, and
severe penalties are imposable for malinger-
ing or false statements regarding illness or
disability; advantage having been taken of ex-
perience with such laws for a number of
years in the section of Alsace-Lorraine.
We can imagine a number of questions you
would like to ask and we regret not being able
to volunteer the answers now, but, as pre-
viously stated, the law has been in operation
for a few months only and we are not suffi-
ciently wise to predict with certainty how it
will work. The probabilities are that time
and experience will effect some changes in
the law, and that physicians will come to feel
less antagonistic to the whole scheme than
they have been.
With this letter we terminate our report of
last year’s travel observations but we may,
possibly, because dealing with development of
health insurance laws in other countries, sup-
ply one more letter to present you with some
information that has drifted into this office
from Canada.
Medical Ethics
“WHO STEALS MY PURSE STEALS
TRASH”
John Hammond Bradshaw, M.D., F.A.C.S.,
Orange, New Jersey
What is there in a name? None can say.
If your name is for sale, you must know its
value. It is surprising to see the low value
of some appraisals. The owner is himself to
blame when he holds his name too cheap. It
should give us pause to think how thought-
lessly and how carelessly we sometimes lend
it. And like other loans, we may not get our
name back ; and even when it is returned, it
may be tarnished, and in that case we surely
do not get it all back. Or, on the other hand,
when we get it back it may be unduly in-
flated or it may be polished to an undeserved
lustre. In this case also the ledger shows
profit and loss ; although the writing may be
hidden, it is in red ink just the same. This
can be true even when the name becomes a
very noisy one.
But, you will say, anyone can write a few
abstract platitudes; they are not real facts.
Let us now look at some concrete statements
which are facts and are surely not falsehoods.
A prominent New York City Judge blandly
admits even this winter on the witness stand
receiving $1000 cash for endorsing a much
exploited brand of yeast. The value of this
endorsement is much enhanced by its accom-
panying photograph of the judge in all official
robes ; the underwriting gives the name and
official title. Was the price $1000 too cheap
or too dear? Who knows?
“Nuxated Iron” once had an extensive sale
as a tonic and strengthener because it was en-
dorsed by Jess Willard, the prize-fighter. We
are not told how much Jess got for his name.
But the advertisement fell flat (after telling
the public it was the cause of Willard’s
strength) when the fighter was knocked out.
Possibly in this case Willard got more than
his name was worth. Was it not a racket?
Almost a half-score supposedly nose and
throat men are now pictured in the daily
press, each wearing a head mirror with not
one patient in sight and the invaluable infor-
mation is given that nose and throat doctors
endorse a certain brand of cigarettes. Do they?
Another racket? Furthermore, we are told
(the voice invading even our firesides) that
over 20,000 doctors endorse another brand
of cigarettes because “they are toasted”. Do
they? Is this still another racket?
The writer with hundreds of others (per-
haps thousands) received, gratis, a very large
package of cigarettes from a certain manu-
facturer of a popular brand with request for
a written statement of the enjoyment afford-
ed thereby. Did the manufacturer get it?
It is flow getting almost too common to
read endorsements. It is quite funny to be-
lieve or ask if people are really taken in and
if they think that the endorsements are given
“on the merits” of the goods. Do not we know
that they are given for cash or value received?
All the cults have their endorsers, even by
the thousands — then just consider the beauty
creams and the number of patent medicines
that are endorsed over the signature “it cured
me”.
There is no end to this, “racket” game — it
pervades not only evil doers but all our mod-
ern life. The spirit pervading our “modern-
istic” morals, like our present day modern-
istic art, is after all nothing but a racket. It is
distorted, grotesque and unlovely, and we
360
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
come into the picture when we give it our own
names.
There is the usual trite (but true) warning
ior us to avoid putting our property in jeop-
ardy by our endorsements. But many an
honorable name has in this way been inno-
cently dishonored and much property has been
lost.
Pressure of friendship, social, political, and
even of family influence leads us to give our
name to certificates of ability or disability or
of some promised benefit. This we are told
will be of great benefaction if not to our-
selves, to others.
Even our charity is made a weakness. Hid-
den away almost out of sight is some diabolic
joker to keep all concerned within the law,
whereas, if justice were served, the law should
take its course.
Esthetics
CONSIDER THE DREAMERS
(From the Kalends, Williams and Wilkins
Co.)
Behold, this dreamer cometh. And Joseph’s
brothers laughed — until they were hungry.
Then it was that they discovered that Joseph
had all the corn — cereal, be it understood.
And he had the corn because he dreamt dreams
that were worth the dreaming. Be not too
severe upon the dreamer, for dreams are part
of all achievement. The course of our present
civilization itself was charted by dreamers ;
by men with clear vision and simple sincerity,
who dared strive and fight in the face of all
opposition with a tenacity that would not be
subdued.
Jesus was a dreamer, and his dreams have
inspired men to heroic deeds and influenced
the course of history in a manner such as no
other man’s life has ever done. And* yet his
dreams even today are but half interpreted.
Columbus was a dreamer, but his castles were
not built in Spain. Pasteur was a dreamer,
but his dreams were not of gold and renown.
Ah, no! The dreams of such dreamers were
rooted, deep rooted, in ideals and purposes.
Such dreams* and their dreamers’ achieve-
ments gave the World a doctrine of hope, gave
America to the world, and helped vastly to
make all of the world a better place to dwell
in.
Sad it is, in a way, that so few dreamers
live to see their dreams come true! Most of
the greatest of them, as is attested by history,
were halted midway between conception and
realization. Life is too short, it seems, to
realize many of the dreams that are worth
while; the best most of us can do is to fling
the torch to others, and cry the age-old chal-
lenge of “Carry on” !
To many of us may and will be denied the
incomparable thrill that comes with complete
fulfilment of a life’s dream. Few are so for-
tunate as an Edison. Yet, if we have dreamed
dreams wo’rth dreaming, our dreams will not
have been in vain; for we will have kindled a
spark of inspiration in the hearts and minds of
those who follow in our paths — our sons, our
daughters,- and their children.
No life, no business, no nation, and no
civilization but what, after all, is built al-
most entirely of the stuff that dreams are
made of — ideals, intangible strivings, long-
time dreams, and adherence to self-sacrificing
principles, all of which must be paid for in
advance with no assurance of return. Our
dreams, our hopes, and our aspirations may
not be, relatively, as vital as those of the mas-
ter dreamers of the ages, but as individuals
our dreams are no less important. While it is
true that all things for us will fade into in-
significance with the coming of tomorrow, it
is also true that tomorrow never comes unto
our children and their children until our yes-
terdays are but a memory— -the stuff of
dreams.
Collateral Reading
. SOME NEW BOOKS
(Reviewed by the Editor)
Having explained in our last article that
Santa Claus had supplied us abundantly with
reading matter for the winter evenings, it
seems necessary to report at this time upon
the pleasure and satisfaction already derived
from those gifts. Perhaps we ought to be
ashamed to say that we found ourselves reach-
ing first for the smallest sized volumes in that
collection, but we are delighted to report that
the very smallest book proved to be' a treasure.
Doctor and Patient
by
Francis W. Peabody. M.D.
Having thoroughly enjoyed this book our-
selves, we are strongly inclined to recommend
it to physicians or members of physicians’
families who have occasion to make a small
gift to some practitioner of medicine. The book
costs but $1.50, comprises fewer than 100
pages, and consists of 4 essays written by the
late Francis Peabody and collected recently
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
361
lor publication by some of his friends. As he
was a distinguished physician and a well loved
teacher, active practitioners will delight in the
sane advice offered in these essays and the
sound judgment displayed in everything that
he has heretofore recorded. This group of
papers deals particularly with his views upon
the relation of the physician to the public,
proper care of patients, interest in scientific
laboratory work and the attitude of medical
teachers, calling upon each such teacher to be
what he indicates as “the soul of the clinic”.
The last essay, alone, is worth the price of
the book, as it consists in an expression of his
personal views through the medium of a let-
ter to his close friend. Professor Longcope,
of Johns Hopkins University.
Our New Progress
by
James Bayard Clark
The second smallest book in the collection
proved also to be extremely interesting though
it dealt with quite another aspect of medical
interest. Our new progress is essentially a
study, an analysis, of the recent period of
“great prosperity” and attempts to answer
the question — What is our new prosperity
worth and what hope for happiness and con-
tentment does it hold? As most of the alleged
prosperity seems to have vanished, interest in
answering the question now is to be found
mainly in the hope that in the future such a
calamitous prosperity may be avoided. Re-
viewing the effect upon different classes of
society produced by the modern craze for
financial success, the author makes a very
hapnv reference to our profession as follows :
“As civilization stands today, the profession
of medicine has a great deal to do. It has, in-
deed, made it possible for civilization to take
on the form it now' parades in. Whether this
is entirely creditable is another matter. The
iact remains, however, that large cities, in-
dustries, wars and commerce as they are at
present conducted could not he maintained
without the aid of this profession. And to its
credit it has stood out pretty well against the
enveloping movement of the industrial forces.
It is a profession fiercely jealous of its in-
dividuality, for it knows that two-thirds of
its therapeutic value lies in the influence of
personality. As a class it is no more inter-
ested in the amassing of money than is the
teaching profession. This collection of cir-
cumstances has made the medical profession
an exceedingly awkward segment of society
for industry to embosom ; yet industry has
not been without accomplishment in this re-
gard, thanks to its ally, charitable endow-
ments.”
Having gained somewhat in strength,
spiritual as well as physical, we felt able to
tackle an 800 page novel with a fancy wrap-
per done in red, blue, green and yellow and
carrying a title that was at least intriguing.
Women and Monks
by
Joseph Kallinikov
The jacket blurb describes this book as a
tremendous panorama of Russian life during
the period between the years 1905 and 1917,
including in the last portion of that period
events attending upon the revolution. It pur-
ports to reveal “the low down” on life in
monasteries and convents in Russia, student
life in St. Petersburg with particular refer-
ence to development of revolutionary fire
brands, the brutal character of life among
peasants, and the effects of commencing in-
dustrialism in the Russian cities. It must be
admitted that, from the literary standpoint,
the book is well written, but one may very well
ask zvhy it was ever written. Fully 50% of
the book consists in recording the licentious
relationships between the monks and the
women with whom they came in contact, either
within or outside of the monasteries, and the
similar loose life of the university students.
If a small fraction of the statements herein
presented be true, one may better understand
the present determination of the Bolshevik
Government to antagonize in every way re-
ligion and religious institutions. It is highly
probable that the basic factor of truth has
been grossly exaggerated in the construction
of a novel designed to set forth such truth.
At any rate, inasmuch as the author and his
backers insist upon the truthfulness of the
picture written, we may accept it as in some
respects measurably descriptive of conditions
precedent to and conducive of the revolution
that took place. And in that respect reading it
helped to put us in a better position to ap-
preciate the next book in the collection.
Soviet Russia
by
William Henry Chamberlin
Here we have a book that deserves to be
read by every American who has any wish
to know what has happened and is happening
in Russia. Chamberlin was for many years,
and we believe still is, an American newspaper
reporter of exceptional talent stationed in
Russia. He seems to know intimately the
people and their language and he reviews the
progress of events from the downfall of the
monarchy, through the Kerensky period and
establishment of the Soviet Republic, up to
the commencement of 1930. We shall not at-
362
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
tempt to review the book — not even to quote
from it extensively — because you will want
to read it in full if you are at all interested in
ascertaining what progress the Soviet has
made up to date. It is by all odds the most
authoritative, and the most satisfactorily writ-
ten, exposition of the plans, efforts and de-
gree of success attained toward the establish-
ment of a government based upon and abso-
lutely controlled by the proletariat — which as
used here is but another name for the union
of working men.
One phase only shall we specifically refer
to, and that because it deals with medical prac-
tice under the Bolshevik Government. Regard-
ing medicine we may quote from Chamberlin
as follows :
“Nikolai Semashko, a country doctor be-
fore the Revolution, has built up an extensive
socalized health service. He is especially
proud of the achievements of his Commis-
sariat in the field of preventive medicine, and
in reducing the formerly high rate of infant
mortality. ***** The Commissariat for
Health plays an important role in the Soviet
Union, because medical aid there has been
largely transformed from a private to a pub-
lic function. The Commissar for Health, N.
E. Semashko, stated that during 11 months of
the year 1927 a total of 49,435 workers and
employees went to private hospitals as against
14,000,000 who received treatment in state
hospitals and dispensaries. The worker’s av-
erage expenditure for medical aid during this
time was 23 kopecks (11)4 cents) most of
which sum went for home medicines. During
the year 1926-1927, the state spent,' on the
average, 30.84 rubles ($15.42) on medical aid
to each worker’s family.
The Health Commissariat is inclined to take
special pride in its work for the prevention
of disease. At the time of the celebration of
the tenth anniversary of the establishment of
the Commissariat for Health, in the autumn
of 1928, Dr. Semashko declared that 2000
doctors were employed in the field of protect-
ing the health of children through regular
physical examinations of school pupils, in-
spections of the sanitary condition of the
schools, encouragement of physical training,
etc. A good deal has been done in the way
of investigating occupational diseases of fac-
tory workers, and a number of experimental
sanatoriums are maintained in this connection.
In medicine, in the provision of hospitals,
clinics, and sanatoriums, as in so many,
branches of Soviet life, one is forcibly struck
by the impression of leveling. Existing
accommodations are, as a rule, inferior to
what wealthy or even middle class people would
command before the Revolution. But work-
ers and the poorer classes who could not in
pre-war times have afforded to pay the fees
of private doctors and hospitals now receive a
much larger share of free medical attention.
The health of the population as a whole seems
to be better than was the case before the war,
if mortality statistics represent a fair criterion.
The death rate in European Russia in 1913
was 27.4 per thousand. In the European
part of the Soviet Union in 1926 it was 19.9
per thousand. There has been an especially
marked decline in infant mortality, due to
legislation for the protection of mothers and
babies. The country has also been free dur-
ing recent years from the terrible scourges of
cholera and typhus, although this may be due
in part to the fact that these epidemics were
so widespread during the period of civil war
that a considerable part of the population ac-
quired relative immunity through contracting
the diseases.”
Chamberlin refers to physicians being
over-worked under the new system but gives
us little information upon which to base even
a guess at the effect otherwise upon the pro-
fession.
In Lighter Vein
Breaking Up
"What is the best thing to do when the brakes
of one’s car give way?” asks a motoring corres-
pondent. Hit something cheap. — Everybody’s
Weekly.
They Don’t Satisfy
A New Jersey doctor says there are fewer girl
sopranos since women started smoking. That’s
the greatest argument we’ve heard in favor of
women smoking.— -Southern Lumberman.
Labor- Saver
“Wouldn’t you be surprised if I gave you a
check for your birthday, Henry?’?
“I certainly would, dear.’’
“Well, here it is, already made out, ready for
you to sign.” — Chicago News.
Honk! Honk!
Driver — “I wasn’t going forty miles an hour,
nor thirty, nor even twenty.”
Judge — “Here, steady now, or you’ll be back-
ing into something!”— Rammer-Jammer.
Economy Plus
“Here comes the parade, and your Aunt Helen
will miss it. Where is she?”
“She’s up-stairs waving her hair.”
“Mercy! Can’t we afford a flag?’?- — Kennebec
Journal.
Jamboree in the Jam
Two little boys were talking. One said to the
other: “Aren’t ants funny little things? They
work and work, and never play.”
“Oh, I don’t know about that,” replied the
other. “Every time I go on a picnic they are
there.”— Boston Christian Register.
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OP NEW JERSEY
363
Current Events
MINUTES OF THE WELFARE COMMITTEE
The regularly called meeting of the Welfare
Committee was held at the Hotel Stacy-Trent,
Sunday, March 1, 1931; being called to order by
the Chairman, Dr. A. Haines Lippincott, at 3
p. m.
The following members were present: Clayton,
Conaway, Costill, Dandois, Davis, Disbrow, Ely,
Green, Hagerty, Haggerty, Hunter, Lee, Lippin-
cott, Londrigan, McBride, McGuire, McMahon,
Morrill, Morrison, Morrow, Nafey, North, Quig-
ley, Schauffler, Schlichter, Sommer, Tracy, and as
guests, Drs. Charles B. Kelley and Marcus W.
Newcomb. Excuses were received from Drs. Don-
ohoe, Haussling and Sherman.
The Chairman called upon the Executive Secre-
tary for the reading of his report which was pre-
sented by Dr. Reik.
Report of the Executive Secretary to the
Welfare Committee
March 1, 1931.
Since we last gathered in consultation a new
legislature has come into existence and we now
have to consider an entirely new crop of proposed
laws; a new crop, but most of the propositions
growing from seeds of the same old hardy peren-
nials. The procedure this year of closing the door
against submission of new bills after February 10
resulted in an avalanche of documents on that
date, and the Legislative Index lists 243 Senate
and 429 Assembly Bills, a total of 672 propositions
for new laws or amendments to existing laws.
Out of this number we have culled for study 3f
(14 S. and 17 A.) which, from their titles, seemed
to have some possible bearing upon medical prac-
tice or upon public health. We secured and have
read all of these Bills and have found that 25 of
them should be reported to this committee.
Before taking up the Senate list, we should say
that with adjournment of the General Assembly
of 1930, the Abell Commission Bills, so-called, in
the form originally presented, passed out of ex-
istence. There was an agreement, however, that
the same or similar bills should have “right of
way’’ in the opening days of the new Assembly.
During the interval between the Assemblies of
1930 and 1931, members of the commission and
the prospective officers of the new legislature held
several conferences concerning this general subject
and, as a result thereof, some of the old bills now
appear in modified form and some have disappeared
entirely. The proposal to combine all of the pro-
fessional examining and licensing boards under a
bureau in the State Board of Education has been
dropped; at least, for the time being.
Among the recently submitted bills, S. 22 and S.
24 take the place of S. 260 and S. 262 of last year;
that is, they provide for the appointment of a
State Budget Commissioner, for paying into the
state treasury all moneys received by government
departments and agencies and for the method of
appropriation of funds to be expended by such
departments and agencies. The State Board of
Medical Examiners is not specifically mentioned
but it would appear to be covered in the provision
for state commissions and boards handling dedi-
cated funds. The Secretary of the Medical Ex-
amining Board will probably inform you today
whether this is a correct assumption.
S. 63, S. 137 and A. 61 propose amendments to
the Workman’s Compensation Law, and all seem
worthy of endorsement; the first named attempts
to clear up differences of opinion in regard to
compensation for “traumatic hernia”, making the
requirements more liberal; the second combines 2
existing laws, which have at times occasioned con-
flict, regarding contracts for employer insurance
to cover liability imposed by accidents to em-
ployees; while the third extends the time iimit for
filing claims. We see nothing to complain of in
any of these bills.
S. 147 applies to the State Health Department
and is said to be for the purpose of providing local
boards of health with power to control sanitary
conditions beyond the minimum requirement of
the general state law.
S. 170 requires the use of distinctive poison
labels for containers of wood alcohol or prepara-
tions made up in part of wood alcohol.
S. 201 seems to be a health department provision
to control the importation of milk and cream into
this state.
S. 202 refers to manufacturers and wholesalers
who supply drugs, medicines and poisons to gen-
eral merchants who have no legal right to sell
such articles at retail.
None of this last group of 4 bills calls for ac-
tion on our part.
S. 161 and A. 63 relate to the hospital lien law
that was passed last year. The first named would
amend that law by striking out, in reference to
hospitals, the words “supported in whole or in
part by private charity”; the second is a new law
outlining the method of procedure for release of
the hospital’s lien against the patient. We have
submitted these to Dr. Londrigan for an opinion.
S. 186 and S. 207 have to do with laws that pro-
vide for the care of war veterans. The first
amends the existing law so as to permit surgeons
of the United States Army, Navy or Marine Corps,
or surgeons in the employ of the Veterans’ Bureau,
to sign certificates of insanity for veterans uncler
observation, and thus to facilitate the handling of
such cases; the second provides additional con-
valescent care for sick veterans upon the “recom-
mendation of reputable physicians”.
S. 221 is an annual registration bill for pharma-
cists but includes provision for limiting use of the
terms pharmacy, drug store, etc., “to places super-
vised by registered pharmacists”.
Assembly Bill No. 1 would make permanent the
temporary commission that was provided 2 years
ago to investigate the number and condition of
crippled children in New Jersey, and provides that
the 9 members of the commission shall consist of
the Director of the State Department of Health, 1
representative from each of the organizations
known as Elks, Rotarians, Kiwanians, Masons and
Lions, and, “3 other citizens of the state” to be
selected by the Governor. Inasmuch as this bill
constitutes a commission “for the care and treat-
ment of crippled children”, we suggest the ad-
visability of providing for at least 1 physician
in its personnel. The bill says about the com-
mission: “They are empowered to inquire into and
ascertain the number, distribution and condition
of crippled children throughout the state, and are
further authorized to provide for the care, treat-
ment, education, and general welfare of such
children.” A very large portion of the work of
such a commission must necessarily deal with the
physical and health conditions of the children, with
the diagnosis, prognosis and treatment of medi-
cal conditions, and yet no one seems to have
thought it necessary to provide for the opinion of
a trained medical man. The bill is in committee
364
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
and might be amended if you consider it wise to
make that suggestion.
A. 29 was introduced by Dr. Newcomb and
would amend the school health laws so as to pro-
vide for the physical examination of school chil-
dren, by school physicians, “with the head, neck
and chest exposed”, under proper conditions. The
bill is on the third reading file and should be
passed.
A. 36 is a proposition to establish an old age
pension system, limited here to those over 65 years
of age and unable to support themselves or to
secure support from relatives. Whether or not it
is a good bill depends upon your personal opinion
of socialistic movements.
A. 104 and 105 determine the procedure for con-
solidating 2 or more hospitals, and we are inform-
ed that it is intended to apply to a situation in
Newark where amalgamation of 2 institutions has
become desirable;
A. 160 would authorize courts of law to order,
before or at the time of trial, x-ray examinations
for the purpose of using the radiographs as testi-
mony in cases based upon alleged injury to the
person.
A. 229 gives school physicians, school nurses,
and school authorities (under varying conditions)
the right to exclude from the class-room children
in an abnormal state of health who might spread
contagious or infectious diseases to other pupils.
We have reserved until the last, 5 bills of more
specific interest to the medical society, mainly be-
cause of their bearing upon the Medical Practice
Act. They are as follows; A. 370 is another at-
tempt to establish a Board of Examiners to select
and license barbers. This bill is without the old
reference to beauty parlors, but it still authorizes
barbers to “remove superfluous hairs, warts,
moles or other blemishes from the scalp, face,
neck or upper part of the body. We think it
should be opposed on that ground, though we must
say, in addition, that we see no good reason for its
passage even as an attempt to make bartering a
profession — as seems to be the object of its pro-
moters.
A. 205 is our old friend, the bill to increase the
rights and privileges of osteopaths, to permit them
to use anesthesia and antiseptics, and to practice
surgery and obstetrics; though these items are
more or less cleverly hidden behind provisions al-
legedly planned to raise the standards for future
osteopaths. It is noteworthy that the term osteo-
pathy receives a new definition and that through-
out the law, amendments would insert the word
surgery wherever reference is made to the type
of practice permitted. The new bill is no improve-
ment over its predecessors, and must be opposed.
A. 207, also introduced by our friend, Mr. Muir,
and S. 155, presented by the distinguished attorney
who once gave us an enlightening address upon
cult practice, Mr. Leap, provide for the licensing
of so-called naturopaths. Mr. Leap still desires a
license for that personal friend whose great knowl-
edge and industry he so fervently expounded in
this room. A. 207 is more liberal in that it would
provide a medical license for almost any applicant.
It provides for a special board of examiners, to
consist of 5 members who may have been for 3
years defying the laws of New Jersey by prac-
ticing without a license, and it defines a naturo-
pathic school as an institution "giving resident
courses in physiotherapy, physicultopathy, sani-
practic , phy somedicine , or any other system whose
curriculum is “recognized by the proposed State
Board of Naturopaths”.
A. 264 is an amendment to the Medical Practice
Act that would make it mandatory upon the Board
of Examiners to issue a license to a person of a
certain type — we take it to mean that individual
who has been striving so long for this special
license.
A. 349 requests the appointment of another
member to the State Board of Examiners — a chi-
ropodist. It is not a bad bill, in itself, and per-
haps our action ought to rest upon the opinion of
the Board; whether its members desire this ad-
dition to their number.
Respectfully submitted by,
Henry O. Reik, M. D.,
Executive Secretary.
Chairman Lippincott : Inasmuch as there are
numerous items in the Secretary’s Report, it would
seem wise to consider them one at a time.
Dr. Reik\ Taking up these legislative bills as
nearly as possible in their proper order, we have
recommended that A. No. 1, providing for the ap-
pointment of a permanent commission on crip-
pled children, should be amended in such man-
ner as to require the appointment of at least 1
physician on that commission.
Dr. Morrison: I move that the Welfare Com-
mittee shall seek the adoption of such an amend-
ment.
The motion was seconded and after some dis-
cussion, during which Drs. Quigley and Costill ex-
pressed disapproval, and Drs. Morrison, McBride
and Newcomb urged adoption, the motion was
unanimously adopted.
Dr. Reik: S. 161 and A. 63, amendments to the
hospital lien law, were referred to Dr. Londrigan
as Chairman of the subcommittee in charge of that
subject.
Dr. Londrigan: I am under the impression that
both bills are satisfactory and should receive our
support.
Dr. Schauffler offered a motion authorizing the
subcommittee to follow up these bills and to use
its own discretion in regard to further amend-
ments; which motion was unanimously adopted.
Dr. Reik: S. 186 and S. 207 authorize army and
navy surgeons to sign certain certificates for
veterans.
After some discussion it was decided not to
oppose those bills.
Dr. Reik: S. 63, S. 137 and A. 61 all refer to the
Workman’s Compensation Law and seem to be
worthy of endorsement.
Dr. Morrison explained that the Advisory Board,
appointed by the Commissioner of Labor, and of
which he is a member, approved the passage of
those amendments. Upon his motion, seconded by
Dr. McBride, approval was given to all 3 measures.
Dr. Reik: Attention was called to A. 370, the so-
called barber’s bill.
Drs. McBride and Morrison pointed out that this
bill might constitute sufficient authorization for
barbers to perform minor surgery, and upon mo-
tion of the former, seconded by the latter, it was
unanimously voted to oppose enactment of this
law.
April, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
365
Dr. Reik: Y'our attention was next directed to
A. 205, the osteopathy bill, and A. 207 and S. 155,
the naturopath bills.
Dr. McBride moved that all 3 bills be vigorously
opposed, and his motion was unanimously adopted.
Dr. Reik: A. 264 is a bill that would provide a
special license for a particular individual who has
not been able to meet the requirements of the
State Board of Examiners.
Dr. Newcomb stated that the author of this bill
had publicly made the statement that this bill has
been endorsed by the Board of Medical Examiners
— and he asked if that statement was true.
Dr. McGuire denied the allegation.
After some discussion, participated in by Drs.
Hagerty, Morrison, Kelley, McBride, Newcomb,
McGuire and Lippincott, as to the best method of
procedure to counteract the statement reported by
Dr. Newcomb, Dr. McGuire accepted a suggestion
made by Dr. McBride — that the Secretary of the
Board of Examiners should write to Assemblyman
Rothermel denying that the Board or its Secre-
tary favored enactment of this bill.
Dr. Reik: A. 349, providing for the appointment
of a chiropodist to membership in the Board of
Examiners, we thought should also be submitted
to that Board for an opinion.
Dr. McGuire announced that the Board is op-
posed to an increase in its number, and thereupon
a motion was adopted to oppose the passage of
this bill.
Dr. Reik: A. 29 is a bill submitted by Dr. New-
comb, which we assume he would like to have en-
dorsed by this committee.
Upon motion of Dr. McBride the committee
unanimously approved Dr. Newcomb’s bill.
Dr. Reik: There remain for consideration only
the 2 bills, S. 22 and S. 24, which take the place of
the 2 budget bills originally presented by the
Abell Commission, and about which we have in-
quired as to the correctness of our interpretation
that they adequately protect the Board of Medical
Examiners in treating the Board’s income as dedi-
cated funds.
Dr. McGuire explained that he understood this
to be the case.
Chairman Lippincott: That concludes our con-
sideration of legislation. Is there any further
business?
Dr. Hagerty: I would like to present the report
of the subcommittee appointed to consider what
action should be taken with regard to control of
the practice of surgery.
Dr. Hagerty read his report (placed on file) and
moved that it be held for publication if and when
any bills should be offered providing for the legal
control of surgery or the surgical specialties. His
motion was seconded by Dr. Londrigan and unani-
mously adopted.
Dr. McBride called attention to the fact that
President Sommer had expended the sum of $100
in the engagement of counsel to represent the
State Society, in conjunction with other organiza-
tions, at the Public Hearing on Abell Commission
Bill A. 304, and moved that the committee author-
ize reimbursement of Dr. Sommer for that amount
from the committee’s budget. The motion was duly
•seconded and unanimously adopted.
The meeting then adjourned.
Henry O. Reik, M.D.,
Secretary.
School Health Department
NOTES OF GENERAL INTEREST
Allen G. Ireland, M.D.,
Director of Physical and Health Education, State
Department of Public Instruction, Trenton, N.J.
School physicians are asked to make a note of
Wednesday, June 3, which is the date for the Sec-
ond Annual Conference of School Physicians held
under the auspices of the State Medical Society.
The meeting will be held in the afternoon at the
Berkeley-Carteret Hotel, Asbury Park. The pro-
gram will be announced in a later issue.
No doubt many school physicians are including
examination of the feet in their annual health ex-
aminations of school children. From information
recently received, it is apparent that Dr. Donald
B. Hull, of Ridgewood, is devoting close attention
to this item. Dr. Hull reports that he is finding a
larger percentage of potential foot troubles than
we would suppose existed. This Department would
be glad to hear from other physicians doing sim-
ilar work.
At least several school physicians are under-
taking the annual examination of teachers. The
exact number is not known, but it is evident from
the trend of opinion that some day greater con-
cern will be shown, for the health of the teacher
than is exhibited at present. There is much to be
said in favor of this activity.
A news clipping just received announces that
Ames, Iowa, has won for the third consecutive
year the silver cup awarded through the National
Tuberculosis Association to that city in the United
States of more than 10,000 population which has
the best school health program. The interesting
point in the announcement is the fact that the
physican’s examinations are conducted annually,
only in grades 1, 3, 6, 9, and 12. In other grades
the physical inspection is given by the school
nurse.
The Trenton Board of Education announces the
appointment of Dr. R. Grant Barry, Psychiatric
Physician, to the Directorship of the Division of
Medical Inspection in the public schools. , Dr.
Barry comes from the State Hospital where he was
a member of the staff.
Cape May County is the first county in New Jer-
sey to have the services of a Helping Teacher in
Health Education on the staff of the County Su-
jjerintendent of Schools. Although this appoint-
ment is in the nature of an experiment, there
have already been achievements reported which
lead to the conclusion that the plan will prob-
ably be adopted permanently for other counties.
Monmouth County followed a few months later
with appointment of a Helping Teacher in Health
Education who is also a well qualified, experienced
school nurse. The prospects for development of
the school health program through the work of
these young women are very bright.
From Union County comes word that a dentist
has been invited by the County Superintendent of
366
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
Schools to act as an involuntary and unpaid su-
pervisor of school dental clinics. This seems to
be a move in the right direction, and the experi-
ment will be watched with interest.
During the winter the writer accepted an invita-
tion to serve as Chairman for Child Health, for the
State Congress of Parents and Teachers. The plat-
form as accepted by the Congress is as follows:
(1) To compose a “Bill of Health for the New
Jersey Child” and to establish its provisions as
the fundamental health objectives in the work of
the Congress and its affiliated units.
(2) To encourage the appointment of an ac-
tive Chairman for Child Health in every unit.
(3) To make available for county and local
chairmen type programs and suggested projects,
and eventually, to have available a handbook on
the conduct of health programs.
(4) To make available for county and local
chairmen a synopsis of an ideal school health pro-
gram in order that local school needs and attain-
ments may be more accurately estimated and bet-
ter understood, thus making for better cooperation
between local chairmen and local school au-
thorities.
(5) To bring about through the state chair-
man, acting as a clearing center, and with the aid
of the county chairmen, an exchange of ideas,
plans, programs, etc., successfully tried by local
associations.
(6) To serve the units and individual members
with respect to information concerning child
health, sources of professional advice, available
current literature, and child health studies.
“The School Physicians' Bulletin” is the title of
the monthly journal of the American Association
of School Physicians. This bulletin and the asso-
ciation are called to the attention of school physi-
cians in New Jersey, and recommended for con-
sideration. Although the association is only a few
years old, it has a large membership from all over
the country. We believe that it is filling a great
need and doing a remarkable piece of work for an
infant. The dues are $2 a year, including sub-
scription to the bulletin. The business manager
is Dr. William A. Howe, State Department of Edu-
cation, Albany, New York.
Governor Larson has called a Conference of
Child Health and Social Welfare Workers for the
purpose of carrying on in New Jersey the recom-
mendations of the White House Conference on
Child Health and Protection. The New Jersey Con-
ference for Social Work has been asked to sponsor
the organization of the state conference. Com-
missioner William J. Ellis, President of the Con-
ference for Social Work, is general chairman. The
meetings will be held at New Brunswick, in the
buildings of the New Jersey College for Women,
and probable dates are April 16-18.
Attention of school physicians is also invited
again to 2 state publications dealing with the com-
municable disease problems in schools. One of
these is Circular No. 191 of the State Department
of Health, called “Communicable Diseases Among
School Children": the other bulletin is “Standards
for the Prevention and Control of Communicable
Diseases in Public Schools”, by the State Depart-
ment of Public Instruction. These are available
without charge, and it is hoped that every school
physician will find them useful in constructing
local programs.
State Health Department
LABORATORY TESTS IN I'NDl'LANT FEVER
D. C. Bowen, Director of Health
New Jersey State Department of Health
Trenton, N. J.
Ever since undulant fever was first recognized
in New Jersey, 2 years ago last month, its diag-
nosis has challenged the medical profession just
as control measures have aroused health depart-
ments. Recognition of 39 cases in the 2 years’
period indicates that physicians are keeping this
disease in mind as a possible cause of prolonged,
unexplained fevers. The further fact that the
laboratory of the State Department of Health now
examines each month for the undulant fever re-
action from 12 to 25 specimens of Dlood shows that
many physicians are seeking laboratory tests in
cases which they suspect may be undulant fever.
Possibly the number of such tests would be greater
if all members of the medical profession knew that
this service is at their command.
The undulant fever reaction is given by the
blood of a moderately advanced case when tested
with a suitable antigen. The antigen used in the
State Laboratory is the widely accepted one made
from Brucella abortus organisms, strain No. 80. A
specimen submitted for the undulant fever test
should consist of 5 to 10 c.c. of the patient’s blood,
prepared in the same manner as a specimen for
the Wassermann test for syphilis. In fact, the
outfit furnished for Wassermann specimens should
be used. However, the request that a test for the
undulant fever reaction be made should be writ-
ten conspicuously in blue pencil or red ink, diag-
onally across the accompanying yellow slip; other-
wise the special request may be overlooked when
the specimen is received and handled with the daily
mail, which often includes 200-300 Wassermann
containers.
Reactions frequently occur in dilutions as high
as 1-1280 in advanced cases. Among 21 New Jersey
cases, the titre reached 1280 in 12 instances and
ranged from 500 to 1000 in 5 others. Agglutination
in dilutions of less than 1-80 are usually not re-
garded as significant.
Of the 39 cases on record in New Jersey (up to
March 15, 1931) 22 have been recognized since
July 1, 1930, when undulant fever was made re-
portable to local boards of health. These 22 re-
ported cases were distributed among the counties
as follows: Bergen, 1; Essex, 4; Gloucester, 6;
Mercer, 3; Middlesex, 1; Monmouth, 1; Morris, 4;
Salem, 1; Somerset, 1.
Those who have studied this diseasie are in
general agreement that the source of infection is
animals, particularly cows, hogs and goats, infect-
ed with the causative organism of contagious
abortion. They are also generally agreed that
mankind is infected through close contact with
such infected animals, or their carcasses, and also
by the use of raw milk containing infection from
the cow.
Pasteurization of milk is, of course, an easy way
to safeguard users of this food against the infec-
tion. Contact with infected animals or meat is not
so simple a problem to solve.
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
367
Woman’s Auxiliary
NOTE from tile editor
In The February Journal, pages 172-173, we re-
produced an article from the Journal of the
Indiana State Medical Association and suggested
that auxiliary members express to the Delineator
.their condemnation of such advertisements. The
President of the State Society Auxiliary, Mrs.
John Nevin, acted upon that recommendation and
wrote a letter to the Editor of the Delineator,
which she graciously allows us to print here-
with. If all members of the Auxiliary and all
members of the Medical Society would follow
this excellent example and denounce newspapers,
magazines and radio broadcasters for spreading
false, misleading and dangerous information or
advice there would surely result an improvement
in advertising and a saving of innumerable lives —
lives that are now sacrificed through the blind
faith of readers in their favorite papers and
magazines. Thousands of readers accept as gos-
pel the deceptive and fraudulent statements pub-
lished as advertising matter by fakers and charla-
tans, and newspaper and magazine publishers
are, in our opinion, equally culpable with the
quacks, because they know that many of the ad-
vertisements handled are false and dangerous,
and they accept for publication, and lend their
support to such fraudulent claims only because
their sense of moral responsibility has become
prostituted to their cupidity. We hope many
of you will rally to this cause. This is a “cause”
large enough to supply every auxiliary with work
to do. Rid your community in so far as possible
of lying advertisements through the local radio
station, and help to clean up the advertising
pages of the newspapers and magazines to which
you subscribe.
Mrs. Nevin's letter was as follows:
Editor of Delineator
Dear Sir:
The members of the Woman’s Auxiliary to the
Medical Society of New Jersey are justly indig-
nant over an article which appeared in the De-
lineator of September 1930, and which has been
reproduced in the February issue of the Journal
of the Medical Society of New Jersey.
The offending article, written by Celia Caroline
Cole, and purporting to advance a remedy for
puffing eyes and wrinkled lids, advises an as-
tringent for the puffiness, cream for the lids, eye
exercises, etc. All to be followed by an adjust-
ment of the nerves in the back of the neck and
backbone by an osteopath.
As President of the Woman’s Auxiliary to the
Medical Society of New Jersey, I voice the senti-
ments of hundreds of members who resent the
spreading of such fraudulent information, know-
ing the harm it could wreak on unsuspecting
readers. May I suggest that, in order to restore
the confidence of discerning wives and families
of reputable physicians, a disclaimer or explana-
tion should come from the Delineator in order
To abate this widespread comment.
Respectfully,
(signed) Mrs. John Nevin.
PANORAMIC VIEW OF THE WOMAN’S AUX-
ILIARY TO THE AMERICAN MEDICAL
ASSOCIATION IN 4 ARTICLES
No. 2. — North Central States
i
Mrs. James Blake
According to the Constitution and By-Laws of
the Auxiliary to the American Medical Association,
the organization program is carried on by the ac-
tive work of the Vice-Presidents. Mrs. Southgate
Leigh, of Norfolk, Va., is First Vice-President and
automatically Chairman of Organization. Due to
her location on the map, the Second Vice-President
finds herself interested in the destinies of the north
central group of states.
Looking backward, with pleasant memories, to
Detroit, and forward with delightful anticipations,
to Philadelphia, we find this group of states all
doing something of common interest.
In the January Journal of the Indiana Medical
Society, the Auxiliary President stresses the im-
portance of more constructive work on the part of
her organized county groups. “Physicians’ wives,”
she says, in her New Year’s Address, “hold an
enviable position in being privileged to have a part
in a world-wide health program, and I would urge
every physician’s wife to bring before other women
dependable knowledge, and a just appreciation of
the real spirit and purpose and actual achieve-
ments of the medical profession.” So, from In-
diana we know we are to have constructive work
during this year. Physicians as a class are not
prone to participate in legislative matters but when
4 separate bills, which affect the profession di-
rectly, are presented during one session of a state’s
legislature, it is time to be up and doing. Such is .
Indiana’s situation this year and the doctors of
the seventh district have thought it worthwhile to
instruct their Auxiliary members on these subjects
that their influence may be properly used. The In-
diana Journal never fails to give the Auxiliary
space, and it is little wonder the Indiana women
are up and coming, when they have such Editorial
Notes to enlighten and guide them in their con-
structive program work, as one finds in this same
Journal.
Kansas is slowly getting a few things accom-
plished. A world-wide depression has rendered
prophets quite fameless abroad as well as at home,
but the doctor’s wife in Kansas is coming into her
own, and we prophesy that the Auxiliary will
climb to the top because of the indomitable spirit
of the leaders in that state.
In Illinois the motto might well read: “Builders
we are, and builders we must ever be. Builders,
not in stone that shelters life’, but builders in life.”
We find good constructive programs of well-bal-
anced educational value, we find a Journal ever
ready to broadcast Auxiliary news, and best of all
we find a healthy organization line-up, and an ad-
visory board from its medical society. Several
of its county groups are having the members
get busy with the “Health Audit Program.” One
project of worthy mention comes from Vermillion
County on the Eastern boundary of the state.
The county auxiliary put on the “Health Insti-
tute” in Danville last November. A member from
every agency in the county working out any kind
of a health program was included in the person-
nel of the speakers. It was for just 1 day, but it
was worth 365 as a rouser for auxiliary work. It
really was sort of a Christmas Seal Campaign
opening, a get together of Club Women, and P. T.
A. groups in the county. And what a wise idea for
368
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
a medical auxiliary to have the headlines in the
plans for such a “Health Day”.
Wisconsin, Iowa and South Dakota are among
the latest states to join the National Auxiliary. Or-
ganization is the key note for their work, and the
National Study Envelopes are offered as program
material. Right now if the modern doctor’s wife
needs to get one thing more than another from
her organization, it is the knowledge of what is
going on in this world; especially the world of
medicine. Women are discriminating more care-
fully in the clubs they are joining. They are ask-
ing what membership will mean to them, what
they will get out of it. For that reason the sub-
jects for study should be more carefully chosen,
and the roll call should be made to count for
something more than jokes and quotations from
forgotten poets. It isn’t a pleasant feeling for a
busy mother who rides miles to a meeting to say
when it is all over: “I can’t say I know any more
now than when I started.” And so we find these
3 states getting themselves established on a firm
foundation, with the national program envelopes
scattered far and wide to aid and encourage Aux-
iliary members, already in, and prospective mem-
bers.
Montana and North Dakota are debating pro-
and-con but as Mrs. Hoxie said in her Detroit re-
port: “I believe it will be a mistake from now on
to organize a new state unless it appears reason-
ably certain that there is interest enough among
the doctors who want the Auxiliary so that they
will foster it and stand back of it.” And so we
leave Montana half-hearted about forming an Aux-
iliary, and North Dakota in the air.
We find Michigan giving intelligent cooperation
with state and county officials. Women, like men,
are interested in the improvement of civic affairs
and healthful living and are realizing that they
need to be armed with a definite knowledge of
health laws and public health practices.
Missouri is in a very healthy condition. We find
that Mrs. A. B. McGlothan, the President-Elect
of the Woman’s Auxiliary to the American Medical
Association, will attend President Hoover’s White
House Conference for Child Health and Protection
to be held in Washington, D. C„ February 19 to
-1. Mrs. G. H. Hoxie, the President for last year,
will also attend the White House Conference.
Mrs. A. W. McAlester tells us the women of
Missouri are finding the Study Envelopes, pub-
lished by the Education Committee of the Woman’s
Auxiliary to the American Medical Association,
most interesting and instructive. The studies on
“Common Defects in Children”, and on “Diph-
theria”, “Small-pox” and “Typhoid Fever” were
recommended by the Department of Health in the
Missouri Branch, National Congress of Parents and
Teachers for use on Parent-Teacher Programs;
800 copies of each were distributed for use in
Parent-Teacher Units; 300 were requested and
supplied for use in Parent Education Classes; re-
quests are constantly coming in for additional
copies of the studies for use by teacher^ and
Parent-Teacher Units. The Department of Public
Information of the Extension Division of the Uni-
versity of Missouri is including these studies in
its suggested programs for clubs in the Missouri
Federation of Women’s Clubs. This department
requested back numbers of Hygeia for use in such
programs. Three hundred copies of Hygeia were
supplied by women in the state and by the circu-
lation manager and are being extensively used in
club programs. The Missouri Chairman of Pub-
lic Relations is planning to have a copy of each
of the studies, “Common Defects in Children", and
“Communicable Disease Control”, sent to each
county school superintendent in the state. Several
of the county auxiliaries are using the study en-
velopes in their programs.
Mrs. M. P. Overholser, of Harrisonville, Mo., has
been appointed chairman of Public Relations in
the Missouri Auxiliary. This Auxiliary maintains
a scholarship for a medical student, per capita
quotas being assigned to each county auxiliary.
They also have sent in 30% of the total number
of Hygeia subscriptions recorded from all auxil-
iaries from January 1, 1930, to January 1, 1931.
Some county auxiliaries provide Hygeia for all
their teachers. Among these are Buchanan, Gen-
try and Lafayette. Cape Girardeau County Aux-
iliary has just finished paying a $1000 pledge to a
hospital in the city and is now ready for another
kind of work. It is a live group and certainly
works hard to be able to accomplish so many won-
derfully worthwhile things.
Minnesota, the North Star State, has had a busy
and successful year on organization. The Presi-
dent and Organization Committee Chairman have
visited over the state and planned meetings and
educational programs with many county groups.
In October the International Medical Assembly met
in Minneapolis, and at this time the Hennepin
County Auxiliary celebrated its twentieth anniver-
sary, by being hostess for 5 days to the visiting
doctors’ wives. A great many social affairs and an
Educational Day, which included a speaker on
public health, were features. Hennepin County is
having a year with a definite program. Each
month a speaker is scheduled, and 1 meeting dur-
ing the year is reciprocity day and each auxiliary
in the state is invited to send visitors. This group
features philanthropic work for T. B. patients at
Glen Lake and does much for the library at the
sanatorium. It has helped the Medical Society
furnish its library and club rooms, spending $1000.
Ramsey County does much the same work. It
has a Scholarship Fund for Medical Students.
St. Louis County is noted for work in the Public
Relations Field. The State Medical Journal gives
a page to Auxiliary news. One of the other coun-
ties takes care of a Nurse’s Scholarship. The Min-
nesota Auxiliary has a splendid Advisory Board
and a page in the State Journal. The President
will be one of the speakers on the program for the
Annual Conference of Secretaries of the Compon-
ent Societies of the Minnesota State Medical Asso-
ciation, to be held in St. Paul the first week in
February. This is the first time the Auxiliary has
been asked to take part in this annual affair. Mrs.
Hesselgrave’s talk will be, “Uses of the Auxiliary”.
And so, closing my review of the work of the
North Central Group of States, may I say again —
Builders we are, and Builders we must ever be
Builders not in stone that shelters life but,
Builders in life itself — ever remembering the fu-
ture of the world for generations to come de-
pends upon what we think and will and do
today.
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
369
Atlantic County
A Report from Mrs. W. Blair Stewart
Since the first of the year the county reports
have come in very slowly, with but 9 counties
heard from — and but 2 have sent in reports for
January, February and March. Of course some of
our counties only have quarterly meetings. Atlan-
tic and Union Counties have had reports each
month. Every Auxiliary should have an active
reporter.
Many attended the open Executive Committee
Meeting and Luncheon at Trenton, which was a
very enthusiastic meeting, as plans were discuss-
ed for both the A. M. A. Auxiliary Convention in
Philadelphia — June 8-12; and also for the State
Medical Meeting in Asbury Park, June 3 to 5 at
the Berkeley-Carteret Hotel.
Among the activities reported are — welfare
work — the deficient child — scholarship funds —
Hygeia subscriptions. There have been flowers
and plants sent to the sick or to those in trouble.
Card parties have been given to raise funds.
Among those who have addressed the various
Auxiliaries were Dr. Harveys Green, Mrs. Taney-
hill, Mrs. A. Haines Lippincott, Dr. Ellen Potter,
Mrs. John Nevin, Mrs. Russell Shirrefs, Dr. Leo
Haggerty, Dr. George N. J. Sommer and Dr. Reik.
Funds are being raised to assist in the enter-
tainment of the Auxiliary Convention in June
in Philadelphia.
Friday, the thirteenth, was not in any way a
hoodoo day, for the Atlantic County Auxiliary
gave a very successful and delightful musicale-
tea in the Solarium of Hotel Claridge on the
twentieth floor (a sure enough sky-scraper for
the seashore!) given to honor our beloved Presi-
dent of the New Jersey Medical Auxiliary, Mrs.
John Nevin, of Jersey City. Mrs. James Hunter,
a Past-President, was also a guest, both giving
us helpful addresses.
The musical program was given by Claridge
Orchestra, with Mr. William Stokking as leader.
An hour’s program of vocal and instrumental
numbers was given by Atlantic City talent, mostly
from those related to the profession. Delicious
refreshments were afterward served.
Claridge Hotel should be called the House of
Hospitality, for the management did everything
possible to make our musicale a success, even
giving the use of its fine orchestra.
Dr. H. O. Reik, Editor of the Journal of the
Medical Society of New Jersey, was the speaker
at a meeting of the Atlantic County Auxiliary,
Friday evening, March 6, in the Blue Room of
Chalfonte Hotel.
Arrangements were made for a card party
about the middle of April to raise funds. Mrs.
Joseph Poland, Vice-President, presided.
After a short business meeting, a social evening
with bridge was enjoyed.
This year the Atlantic County Auxiliary mourns
the loss of 3 valued members from its family.
With Mrs. Beckwith, our President, we mourn the
loss of Dr. J. T. Beckwith, who was taken away
suddenly. Mrs. Mark Haley was the next whom
death called, and now we are deeply distressed
at the passing on of our friend and member, Mrs.
Samuel Barbash. She had assisted in the organ-
izing of the Atlantic County Medical Auxiliary
and was always graciously willing to give of
herself and of her talents.
MRS. SAMUEL BARBASH
The Atlantic City Press published on March
15 an editorial, on the passing away of Mrs.
Barbash, of such character that we use it here
as a memorial tribute.
The unexpected death of Mrs. (Ann Tomlinson)
Barbash yesterday created genuine sorrow in no
small group of native Atlantic City folks. The
reason was perfectly plain. She had been so
gracious and generous in her personal devotion
to friendships, to all worthy endeavors in the
social, church and musical life of the city, and
to the interests of those who were either her
friends or for any reason sought her help. While
exceedingly active in the historic, fraternal and
patriotic societies of all New Jersey, Mrs. Bar-
bash's greatest single contribution to this com-
munity perhaps was her success in gathering,
keeping alive and helping to preserve the inter-
esting historical facts and traditions of Atlantic
City and this immediate section of New Jersey.
In this task her energies were tireless and her
achievements will . endure as of substantial value
tc this and succeeding generations interested in
local history and local genealogic research.
Bergen County
Reported by Mrs. Michael Sarla
The regular monthly meeting of the Woman’s
Auxiliary to the Bergen County Medical Society
was held at the Nurses’ Home of the Hackensack
Plospital on the evening of March 10, with 16
members present.
After the business meeting interesting motion
picture films of California, Panama Canal, and
Honolulu were shown by Mrs. George Finke of
her recent travels there. Delightful refresh-
ments were served in which the Bergen County
Medical Society joined us.
A public card party took the place of the
February meeting and the sum of $100 was real-
ized. The money will be divided between the 4
county hospitals.
Essex County
Reported by Mrs. F. J. Conley
The Woman’s Auxiliary to the Essex County
Medical Society has concentrated its efforts of
the past month on the Scholarship Fund. The
Theater benefit held on March 9 and 10, at the
Lyceum Theater in East Orange, was a most en-
couraging affair. Our doctors attended in goodly
numbers so that social success was added to
financial.
At our March general meeting, we hope to be
enlightened on the work done by the Visiting
Nurses’ Association; an address by one of the
Association’s members.
We were honored by an invitation to attend
the March meeting of the Essex County Medical
Society at the Library Building in Newark.
Gloucester County-
Reported by Mrs. Henry B. Diverty
The meeting of the Gloucester County Medical
Society Auxiliary was held at the Woodbury
Country Club, Thursday, March 19, at 9 p. m.,
370
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
President, Mrs. Elwood Downs, in the chair. Con-
sidering the stormy weather our members were
very well represented. Mrs. James Hunter, of
Westville, a member of our auxiliary and also
of the State Board, brought to us in detail the
program of entertainment by Pennsylvania, New
Jersey and Delaware Auxiliaries to the A. M.
A. Convention, to be held in Philadelphia, June
8 to 12.
A letter from headquarters regarding circula-
tion of Hygeia was read and discussed. After
transacting the routine business, we adjourned.
With the coming of the auxiliary and its work
a new and greater friendliness has come to us.
The atmosphere of our medical people is entirely
changed.
The doctors held a meeting at the same hour
in another part of the building. After they ad-
journed, we joined our forces and went to the
dining room where a fine collation was served
by the Country Club steward, and a very enjoy-
able social hour followed.
Hudson County
Reported by Miss Anne Hetherington
The February meeting of the Woman’s Auxili-
ary to the Hudson County Medical Society was
held in the Jersey City Y. W. C. A. on Friday,
F'ebruary 27.
It was voted that $100 be distributed among
local charities.
After the business meeting, a talk by Mrs. E.
C..Taneyhill, Field Secretary of the Medical So-
ciety of New Jersey, on “Mental Hygiene’’ was
enthusiastically received, proving the lively in-
terest this subject is arousing everywhere today.
Mrs. Taneyhill graciously discussed many points
of her address with the members during the in-
formal tea hour which followed.
The President, Mrs. John Nevin, again made a
plea for a large attendance at the State Medical
Society Convention to be held in Asbury Park,
June 3 to 5, reminding the members of the attrac-
tive plans made for their entertainment.
Mrs. Nevin also presented the social, scientific
and historic advantages to be enjoyed at the
American Medical Association Convention at
Philadelphia, June 8 to 12, concluding her talk
with the reminder that every member should
consider it a personal obligation to play her part
as hostess on the New Jersey Day assigned to the
State Auxiliaries.
Somerset County
Reported by Mrs. Abram Levy
The Woman’s Auxiliary to the Somerset County
Medical Society held the third meeting of the
year on Thursday afternoon, February 12, at the
Nurses’ Home of the Somerset Hospital.
It was decided to hold a card party in April,
ihe proceeds of which would be used for enter-
taining at the A. M. A. Convention in Phila-
delphia.
Delegates were elected for the State Society
Convention at Asbury Park. The first delegate
is Mrs. Edgar Flint, of Raritan, and her alternate
is Mrs. R. K. Adams, of Skillman. The second
delegate is Mrs. E. G. Brittain, of Bound Brook,
and her alternate is Mrs. Abram Levy, of Somer-
ville.
Union County
Reported by Mrs. C. A. Hoffman
The first of a series of afternoon meetings was
held by the Woman’s Auxiliary to the Union
County Medical Society in the Winfield Scott
Hotel, Elizabeth, on February 16. Nearly 40
guests and members sat down to the luncheon.
The President and President-Elect of the Aux-
iliary to the State Medical Society, Mrs. John
Nevin, of Jersey City, and Mrs. H. Roy Van
Ness, of Newark, were guest speakers.
Mrs. F. A. Kinch, of Westfield, a Past-Presi-
dent of the Union County Auxiliary, outlined the
spring program. Mrs. George L. Orton, another
Past-President, reported plans for entertainment
of the Auxiliary members at the meeting of the
New Jersey Medical Society, in Asbury Park,
June 3, 4 and 5, and those of the American Medi-
cal Association, in Philadelphia, June 8-12.
Mrs. H. V. Hubbard, of Plainfield, President of
the Union County Auxiliary, presided. At the
close of the meeting the following officers were
presented: President-Elect, Mrs. Harold Cor-
busier, of Plainfield; Vice-Presidents, Mrs. Nor-
man Currie, of Plainfield, and Mrs. George L. Or-
ton, of Rahway; Secretary, Mrs. Charles A. Hoff-
man, of Plainfield, and Treasurer, Mrs. Denis
McElhinney, of Elizabeth.
County Society Reports
ATLANTIC COUNTY
John S. Irvin, M.D., Reporter
The regular monthly meeting of the Atlantic
County Medical Society was called to order at 8.30
p. m., March 13, by the president, Dr. Norman J.
Quinn, at the Chalfonte Hotel. The minutes of the
previous meeting were read and approved by the
secretary, Dr. Joseph H. Marcus.
The names of Drs. Timberlake, Roark and Kline
having been approved, they were declared elected
to membership.
Public Health and Sanitation Committee: Dr. W.
Blair Stewart said Don D. Modica, convicted of
practicing without a license, was fined $500 or 200
days in jail.
He brought up the question of advertising
patent medicines over Radio Station WPG. This
station now broadcasts nightly at 11.30 a talk on
patent medicines. The matter will be taken up
with Mr. Spence who is in charge of the station.
Last Tuesday evening the Atlantic City Auto-
mobile Club took up the question of drunken driv-
ing. The general medical profession of Atlantic
City has been blamed very seriously upon this
question. Any member of the medical society who
pronounces a man drunk should stand by his
point.
Dr. Scott, one of the oldest practitioners in the
city, is ill, and it would be nice if the committee
would communicate with Mrs. Scott and offer the
services of the society.
Dr. Senseman said it was a disgrace to the
medical profession the way drunken driving is
handled in this city. The Atlantic City Hospital
interns cannot pass upon whether a person is
drunk or not, as they are not registered physi-
cians, and secondly the hospital isn’t a police sta-
tion. The drunken man should not be sent to the
hospital just because the present police surgeon
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
371
refuses to do that work. In regard to the broad-
casting, the committee will be very willing to take
the matter up. Since WPG was taken over by
Columbia it is a commercial proposition and we
must take this into consideration.
A motion was passed that the society go on
record as protesting against this radio broadcast-
ing of patent medicine.
The treasurer’s report was declared to be cor-
rect, by Dr. Homer I. Silvers, who audited it.
A letter of appreciation was received from Dr.
Henry O. Reik, who was elected an Honorary
Member at the last meeting.
A motion was passed that the society purchase
a copy of “American Physicians and Surgeons”
and present it to the library.
Dr. Harvey spoke about a plan which is on the
order of “Know Your City Day”; the idea being to
sell Atlantic City to Atlantic City and the com-
munity. The members of the committee could
meet with the Chairman of the Chamber of Com-
merce. He said that the doctors could join in by
giving exhibits of child welfare, an exhibit of x-ray
work and baby welfare clinic, tuberculosis and
red cross work, etc. The doctors can do nothing
as individuals but as a body they could show the
health work that is being done here in the city.
It must be done under the auspices of the County
Society. Booths are being sold in the Convention
Hall for this purpose at $10 per 100 sq. ft. The
question that comes into our minds is, do we want
to enter it? A motion was passed to appoint a
committee to consider the advisability of this. The
president appointed Drs. Harvey, Conaway and
Silvers.
Dr. Stern spoke about a so-called “racket” being
practiced by the insurance underwriters. He said
they are sending patients to get treatment at the
state rehabilitation clinic at $1 per patient. He
complained bitterly of physicians’ fees being ar-
bitrarily reduced by the insurance companies, and
made the charge that some members of the society
are doing compensation work at cut-rates by con-
tracts with the companies. He thought that the
insurance companies should not determine the fees
that the doctor shall charge.
Dr. James Mason, who is the State Compensation
Commission’s doctor for this district, spoke. He
said he is in charge of the state clinic and that
treatment is given there at the price of $1 per
treatment. In the Rehabilitation Clinic they re-
ceive cases referred from other doctors. Cases are
also sent from the Workman’s Compensation Court,
which is a part of the Department of Labor of the
State of New Jersey. He read the Act which was
passed by the legislature of the state of New Jer-
sey. He then explained that a committee is ap-
pointed under this Act to pass upon all disputed
medical fees in compensation cases. Dr. Allman
is on this committee as a representative of this
society. Dr. Pilkington is on it as a representa-
tive of the insurance companies and Dr. Mason
represents the state. The committees were ap-
pointed with the idea of avoiding legal complica-
tions. If a physician is not satisfied with the rul-
ing of this committee he has recourse to the Com-
mon Law Court. The insurance company doesn’t •
dictate the fee. The Act itself states the fee. Dr.
Mason went on to say that as far as contract work
is concerned he does a great deal of this compen-
sation work and he has no contract with any in-
surance company or with anybody and that he
charges his own fees.
Dr. Allman : The companies treat you right if
you go about it in the right manner. There are
some doctors who try to rob insurance companies.
I, personally, know that some members of this so-
ciety have charged for visits that were never
made, and that is why the companies are prone
to send their patients to doctors whom they can
trust. We do not try to favor the insurance com-
panies nor do we try to “gyp” them. It is much
better to go along with them in a friendly man-
ner than to try to get an exorbitant rate and so
throw unjust reflection on the whole society.
Dr. Senseman said there is no reason why an in-
surance company should be robbed. Quite often
it receives large bills for negligible services.
Therefore, the dishonest doctors make it bad for the
honest doctors. The trouble is more often with us
than with the insurance companies.
Dr. Marcus announced that on April 10, there
will be no regular meeting. Instead, there will be
a meeting of the Fifth Councilor District of the
State Medical Society at Haddon Hall at 4 p. m.
The speakers at this session will be, Dr. John A.
Hartwell, President of the New York Academy of
Medicine, who will speak on, “The Continued Edu-
cation of the Doctor”, and Dr. Joseph Doane, Di-
rector of the Jewish Hospital in Philadelphia, who
will speak on “What the Public Thinks of the
Present Day Practice of Medicine”. The after-
dinner speaker will be Dr. H. Sheridan Baketel,
Professor of Preventive Medicine in the Long
Island College of Medicine, and he will speak on
“The Personal Element in Medical Economics”.
At 8.30 p. m. there will be a Clinic at the Atlan-
tic City Hospital where interesting cases will be
shown. Refreshments will be served after the
clinic.
Dr. Quinn hopes the members will turn out
100%.
Then followed a talk by Dr. Ernst P. Boas,
Associate in Medicine in the Mt. Sinai Hospital,
New York, on “Rheumatic Fever”.
Dr. Boas. The subject I have chosen to speak
about is such a vast one that it is difficult to know
what to put in and what to leave out. I felt
that rheumatic fever is such an important prob-
lem to all of us, in view of the fact that one-half
of all cases of heart disease and nearly all cases
of heart disease in children are caused by it.
Definite knowledge as to its cause is still very
scanty.
First of all, I should like to emphasize the fact
that rheumatic fever is an infectious disease like
meningitis, poliomyelitis and pneumonia. What
evidence have we to substantiate this point of
view? Rheumatic fever, in its seasonal distribu-
tion, resembles many infectious diseases. Over a
period of 30 to 40 years this incidence may be
high and then again the incidence decreases.
There are definite waves that occur, due to an. un-
known fact. In this latitude the disease exists
and begins to get scattering in the fall, but from
March to May the incidence reaches its greatest.
At the present time we are receiving many cases
in our hospital in New York. There is a very
interesting problem about the contagiousness of
rheumatic fever. Most of us have not thought
about it as an infectious disease. It can be trans-
mitted from one person to another. Yrears ago
cases were described of one child developing
arthritis and then the mother or some other mem-
ber of the family contracting the disease. Then
some 30 odd years ago there was pointed out the
marked frequency of rheumatic fever in families,
due to hereditary predisposition. Environment,
rather than heredity, determines the high inci-
dence of many cases in a family. In the brothers
and sisters and parents who attend my cardiac
clinics I found that in their families multiple cases
372
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
occurred. Rheumatic valvular heart disease was
much more prevalent in rheumatic families.
Finally, very definite epidemics have been ob-
served and described.
During the War, the French noted definite evi-
dence of epidemics in regiments. It was not con-
ditioned by environment, as only the originally in-
fected regiment kept on having the disease. I have
had the good fortune of observing 2 epidemics in
the children’s wards of the Montefiore Hospital.
In the first one there were 18 boys with old rheu-
matic heart disease in a ward. One child began
with an acute rheumatic infection and then after
a month about 8 other children became infected,
and several died. The second epidemic was sim-
ilar. However, this disease hasn’t a high degree
of contagiousness, like measles. It is like polio-
myelitis, in which infection occurs but which is
not very common. Environment also plays an im-
portant part. The disease is found among the
poor. It is like tuberculosis in this sense, where
the economic status of the people makes it hard
to prevent the disease.
The first point to remember then is that it is
an infectious disease partaking of the general
character of the general infectious diseases.
If you study the incidence of the disease in the
L^nited States and compare the *North with the
South you will find that going from Boston south
it diminishes tremendously. It will suffice to say
the disease is rare south of Virginia. In the
tropics the disease is almost unknown. I have
been interested in studying the incidence in Porto
Rico. A large settlement of Porto Ricans live in
the vicinity of the Mount Sinai Hospital. Among
them we have seen cases of acute rheumatic fever,
but with very few exceptions they all contracted
their infection after arriving in the United States.
I took pains to check up the morbidity and mor-
tality statistics. What is true of Porto Rico is
true of the tropics in general. Not alone rheu-
matic fever but other diseases, such as scarlet
fever of streptococcic origin, do not tend to spread.
Mouth cultures have shown that the streptococcus
is very common there. So the matter is not as
simple as it sounds.
Recently some, physicians in the Presbyterian
Hospital made an experiment. They sent some
rheumatic patients to Porto Rico and while they
were down there their symptoms subsided. This
points to a very practical conclusion in regard
to children especially. It may be very wise to ad-
vise parents to send their children South. I would
send them south in September or October and
keep them there until June. This measure is a
practical method of treatment of the disease where
the patient’s means will allow.
The heart needs little comment. We know that
when the endocardium is attacked the myocardium
is attacked as well. Not the heart itself, but the
large vessels are attacked too, even lesions of the
pulmonary artery have been described. The lungs
are commonly involved in rheumatic fever. A few
years ago Nace described rather characteristic
rheumatic pneumonia. Rheumatic pleurisy we
are all familiar with.
Rheumatic pneumonia is associated with other
manifestations. Physical signs are very definite.
The brain is also at times involved. Cerebral rheu-
matism is probably an encephalitis. The perito-
neum may' be involved. I would like to call your
attention to the frequency of severe abdominal
pain and rigidity. It is not at all uncommon for
a child to be taken with chill, rigidity and pain in
abdominal region. Appendectomies have been per-
formed and within a week the patients developed
arthritis. This has been overlooked in recent
years, and we seem to have forgotten about it
until in the last few years papers have appeared
upon the subject. The skin is frequently involved.
We have all types of skin eruptions. The sub-
cutaneous tissues are also involved. The anemia
of the disease may be due to involvement of the
bone marrow. I have enumerated all of these items
to impress upon you that rheumatic fever is an
infectious disease which may involve any part of
the body. In any case the virus is widespread.
What is the etiology of the disease? Very little
is actually known. While many observers have
been believed to isolate the germ (streptococcus)
we cannot reproduce the disease in animals. We
do know that it is often associated with tonsillitis.
Glover observed a tonsillitis epidemic among 3530
soldiers — 427 cases. Within 2 weeks following on-
set of the tonsillitis he found some 40 cases of rheu-
matic fever. Schlesinger also made similar ob-
servations. It usually occurs from a period of
from 10-21 days after the onset of the tonsillitis.
The tonsils have been accused of being the por-
tal of entry. The whole respiratory tract, the
nose, nasopharynx, lungs and tonsils are all portals
of entry for the rheumatic virus, but I do not be-
lieve that any one particular tract is more of a
portal than another. I have seen rheumatic fever
very frequently in people who had no tonsils but
who had attacks of pharyngitis, so I think we are
mistaken when we localize too strictly.
Dr. May Wilson and some associates in New
York followed the course of 400 children from 1 to
10 years. Over half of these children had their
tonsils carefully and completely removed, yet 48%
developed rheumatic manifestations. It was found
that as the children became older the rate of infec-
tion became less. As children grow older they
become less susceptible to rheumatic infections.
We must regard the whole respiratory tract, upper
and lower, as a possible portal of entry, and that
even after the tonsils have been removed the pa-
tient may get pharyngitis.
Under what conditions and when should tonsils
be removed? I believe that the history is impor-
tant. Not in the hope of preventing heart dis-
ease but in the hope of preventing severe follicular
tonsillitis. You cannot tell by looking at the ton-
sil whether it is infected. Tonsils and adenoids
that are so large that they make breathing diffi-
cult are indications for removal of the tonsils; also
otitis media. In years to come there will be less
removal of tonsils than there is at the present
time.
What lesions may we expect in the heart? The
first of these is the immediate heart lesion accom-
panying the acute infection, an acute myocarditis
and endocarditis. In the acute stage of the dis-
ease we need not worry about any dynamic effects
of valvular lesions. We have to worry about the
actual effect on the cardiac function. The heart
in order to maintain its work, even when the pa-
tient is actually at rest must be quite rapid. These
patients react very poorly, even to the very slight-
est effort. To complete these children’s immobil-
ization. I should not have such a child move about
in bed or even feed itself, and would watch very
closely to prevent even the most minimum effort,
as I have seen such children suddenly sit up in
bed and drop dead from the effort. These children
should be placed in bed for a long period of time.
Once the fever has gone down, we send the chil-
dren home. This is a mistake, as after the fever
has been down 10 or 15 days these children should
be kept in bed at least a month longer to make
sure that their fever will stay down. This is the
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
373
only way we can minimize to a slight degree the
serious effects.
Then, of course, we have a large number of late
heart lesions, the after-effects of acute heart
lesions. Are there any cases which recover com-
pletely? There are, undoubtedly. There are some
who are spared any cardiac involvement whatso-
ever. There are some who have a definite valvular
disease who are fortunate in having only one re-
infection, but since they are spared further re-
infection there is slight incapacity and as the
heart grows with the growth of the child this
never again bothers the individual. However, in
these cases in which the original valvular defect
is slight such defect may in later years be the site
of sclerosis sufficient to give symptoms of heart
disease. Such cases, I believe, are not at all
uncommon.
1 said nothing at all about the myocardium.
There apparently is no permanent damage here.
The acute inflammation leaves a few small scars,
the so-called Aschoff nodules. The function of the
heart is not impaired.
A few brief words as to treatment and prophyl-
axis. There is no other disease in which treat-
ment is so unsatisfactory. We have no means of
counteracting the rheumatic virus. We have a
few facts that are sufficiently suggestive to use
as a plan of therapy. I wish to repeat that
wherever it is possible for a patient, send him
south, with the fairly good assurance that the dis-
ease will be arrested after a few months.
I believe that the time is coming soon when the
sanatorium treatment of rheumatic fever is going
to be adopted just as for tuberculosis. I should
like to repeat one word about the tonsils. In some
cases it is not only futile but dangerous to re-
move them. As for medication, there is no medi-
cation.
Give the patient absolute rest. While there is an
acute myocarditis, digitalis is of no earthly good.
It acts as an additional toxin. Salicylate is often
given in too great doses. We must remember that
it is a chronic disease and that the fever may con-
tinue for weeks or months and we must support
the patient and feed him. Don’t keep these pa-
tients on a liquid or soft diet, but give whatever
they can stand — anything within reason.
What is the criteria for recovery? When he
shows no longer progressive wasting and anemia.
The return of the sedimentation time to normal
may help. We have no accurate method of attack-
ing the disease. Just as tuberculosis is decreasing,
so is the incidence of rheumatic fever decreasing
because of the better economic conditions of the
public. We know that it is a poverty disease to a
great extent and when we have better housing
conditions the disease will be less prevalent.
Discussion
Dr. Scanlan. As regards the removal of tonsils,
our hospital staff would be glad to hear your talk,
so that they would have fewer tonsils to take
out. A few cases never prove anything, but we
had a case of a girl suffering from acute nephritis
and she didn’t show any signs of improvement as
time went on. Upon removal of her tonsils her
temperature dropped to normal. The same thing
happened with a case of rheumatic fever; the girl
got better as soon as her tonsils were removed. We
had the case of a nurse who was suffering from this
same illness, who went home in February to Ot-
towa, Canada, and I believe that the climatic
change killed her. I decided to have my 4 chil-
dren’s tonsils taken out at once. The healthiest
child in the bunch, and who is still the healthiest,
had hers taken out, only because the rest were
having theirs out. When they took hers out they
found that she had an abscess with a green
foul smelling pus that no one would have ever
dreamed was there.
Dr. Stewart. I was just wondering whether Dr.
Boas noticed whether during the epidemic of in-
fluenza there was any coincident increase in cases
of rheumatic fever. I have come in contact with
more acute rheumatic conditions in adults than
I have with children. I know of a patient
whose kidneys were very bad and whose tonsils
were supposed to be the best by otologists and
laryngologists, and upon operation a very marked
purulent condition was found, just as in the case
of Dr. Scanlan’s child. Some of these bad after-
results would be prevented if the children were put
to absolute rest. I wish to thank Dr. Boas per-
sonally for a most interesting talk.
Dr. Andrews. In my undergraduate work, where
I studied in a school at the mouth of the Missis-
sippi River, we didn’t see a case of this kind among
1000 men and we were curious to know why.
We were following a lot of Cabot’s work and we
didn’t know those diseases when we saw them.
We learned that they didn’t have these cases to
deal with much in the South. When I went to Bos-
ton I found that out.
Dr. Davidson asked Dr. Boas what his opinion
is of Small’s serum.
Dr. Barbash. One thought that struck me as Dr.
Boas went over the field in discussing the treat-
ment was that he gave very little encouragement
as to any particular treatment. At one time you
talked about using serum and you immediately be-
gan to brag about the results you got with that
particular form of treatment. I saw one case in
particular that got better with mercurochrome in-
travenously and we all know that we have never
been able to find one specific cause if there is one
specific cause. We shouldn’t throw out the var-
ious forms of treatment merely because they
haven’t been of benefit in a specific form of the
disease. The idea of sanatorium treatment for
rheumatic fever is an excellent one and I believe
there is one such institution in Philadelphia and
the particular form of treatment as outlined by Dr.
Boas is being given there.
Dr. Quinn asked Dr. Boas to give some of the
school nurses present some hints as to the treat-
ment of chorea and about the various forms of
exercise for school children.
Dr. Boas. I over-emphasized my attitude about
the tonsils in order to drive my point home.
As for Dr. Stewart’s question, I am not sure
that there was a definite increase of rheumatic
fever following influenza. We see patients who,
following sinusitis, develop clinical instances of
heart murmurs and we don’t know whether to call
them rheumatic.
Small’s serum has not been found useful by any
of the men in New York who are interested par-
ticularly in rheumatic fever. Just how we are go-
ing to treat these patients will depend upon our
temperaments. Some will try to keep the patients
in good shape and bide our time. Others will get
restless. It is perfectly legitimate to experiment
around as long as we are not radical.
One can speak for hours of the relationship of
the school to the rheumatic child, and it is difficult
to bring out the view points that are of the great-
est importance. We are faced with 2 alterna-
tives. We must not make the child too heart con-
scious. On the other hand, we must not allow
the child’s lesion to go on unchecked, and so these
children require very careful handling. The teach-
374
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
ers should be aware they are dealing with a rheu-
matic child. Great care should be exerted to seg-
regate these children from other children suffering
with colds and tonsillitis. As far as handling of
the acute infection, it can only be a matter of
constant attention. What are we going to do with
the children who have regular heart disease? In
New York they have special cardiac classes. The
drawback of this is that the children have their
attention fixed upon .their illness. Yet, in New
York, where the children have to be rushed up and
down stairs, it is better that these children be
segregated in special classes. The important thing
to teach these children is leisure. lrou can stop
pushing the child. In general, children are under
too much of a strain. A child with a mild heart
lesion should climb leisurely up the stairs, and if
he lives too great a distance from the school
should not go home for lunch. He should avoid
competitive games. When he does play in games
and becomes a little short of breath he should sit
down. A child like this usually knows when he
has had enough. Children don't need regular sys-
tematized exercise. This means with the excep-
tion of a few older girls between the ages of 12
and 16 who sit around most of the day and don’t
do anything much at all. Setting-up exercises
are a waste of energy.
Children with chorea certainly don’t belong in
school. Chorea starts in with an acute rheumatic
infection and it winds up as a habit spasm and
you don’t know when infection is over and when
the habit begins. Many people believe that only
children who have predispositions to nervousness
will acquire this habit spasm.
I had the case of a boy of 15 who couldn’t even
talk, or drink water, as his tongue would go con-
tinually. After 2 months we gave the boy a very
large dose of chloral and when he came to he
tried to move, but as soon as he did so the nurse
would quiet him and tell him to lie still, soothing-
ly. He became cured in this way. Yrou will have
to look into the conditions of these children at
home. They set up a very bad example to other
children.
Atlantic City Hospital Staff
Joseph H. Marcus, M.D., Secretary
The stated monthly meeting of the General
Staff was held in the Auditorium of the Hospital
on February 27. The meeting was called to order
at 8.30 p. m. by Dr. Milton S. Ireland, President.
The Scientific Program was presented by Dr. Walt
Ponder Conaway, Chief of the Gynecologic Ser-
vice, and Dr. J. Carlisle Brown, Assistant.
Dr. Conaway. I submit herewith a report of the
work performed in the Gynecologic Service of the
Atlantic City Hospital, from August to Decem-
ber 1, 1930. During that time 133 patients were
admitted; ^92 white and 41 colored. Of these pa-
tients, 117 were subjected to operations. If a
patient had both major and minor operations, it
is counted in this report as one. Seven declined
to accept our offer of assistance by surgical means
arid 8 were cured or improved by medical care;
a patient with inoperable general pelvic and ab-
dominal carcinomatosis, referred from the Medi-
cal Service, died while arrangements were pend-
ing for removal to her home in Philadelphia.
An itemized list of operative work is appended.
Of the 117 operative cases, 107 patients were con-
sidered as cured, 6 improved and 4 unimproved.
There were no postoperative deaths. Eight patients
were given radium treatments; in 4 the diagnosis
was carcinoma of the cervix, confirmed by biopsy.
In the other 4 patients, radium was used for the
control of uterine bleeding and in 2 of these it
was used as a palliative measure only.
The average number of days spent in the hos-
pital was 11.5 for the white and 15 for the colored
patients. One patient from the previous service
remained in our ward for 102 days; 1 of our own
patients remained 80 days and another 57 days,
which increased our average of hospitalization
t ery materially.
Gas-oxygen was used routinely and only in a
few cases was this anesthesia supplemented by
ether. Two patients were given spinal anesthesia
on account of pulmonary and cardiac conditions,
which rendered inhalation anesthesia more haz-
ardous. Dr. Johnson, of the Surgical Service, ad-
ministered the spinal anesthetic very skillfully
and both patients made an uninterrupted re-
covery.
Two patients proved to be of much more than
usual interest and I have asked my assistant, Dr.
Brown, to report these cases to you more in de-
tail.
Thirty-one consultations were held with mem-
bers of the Medical and Surgical Service and we
were asked to see 13 patients in consultation.
During the last few weeks of our service, we
used sodium amytal in 3-6 gr. doses instead of
morphin and atropin preliminary to anesthesia,
and I am inclined to think the patients were less
apprehensive and that they were afforded some
protection against the undesirable psychic ef-
fects of the operating room. They seemed equally
as comfortable and relaxed before operation and
theie was less postoperative nausea and vomiting.
The X-Ray Department and the Department of
Radiology cooperated with us in every possible
manner, and I desire to add a special word of
commendation for their very prompt and efficient
service. The rather plethoric condition of the
finances of our Radium Fund is also deserving of
’some comment. The Hospital Laboratory was of
veiy great assistance. Our requests were an-
swered promptly and the desired reports never
delayed.
Our service the past year was the largest we
have ever had. The work of our interns was very
satisfactory and I was very happy indeed to give
them an opportunity to operate whenever pos-
sible.
Dr. J. Carlisle Brown : We have selected 3 cases
which have unusual features that may be of in-
terest. The first case is of a nulliparous married
woman who came to the hospital with history
of pain of 2 months’ duration in the left lower
quadrant. Temperature was 100°, pulse 110 and
there was a mass 5 cm. in size in the adnexal
legion. She was able to walk about the wards
and did not have an extreme amount of pain.
Diagnosis of salpingitis was made, with a possi-
bility of ectopic gestation. The next morning I
was called from the delivery room when the day
nurse came on duty and the diagnosis was then
obvious; she had all the symptoms of severe in-
traabdominal hemorrhage. The night nurse had
apparently failed to notice the condition. She
was immediately taken to the operating room and
the operation begun, but she almost immediately
became pulseless. An intravenous injection of
saline was starred and 1000 c.c. given. As the
pulse was still imperceptible the injection was
continued. At 1300 c.c. the pulse became per-
ceptible and the injection was stopped after 1500
c.c. had been given. The operation was finished
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
*75
as quickly as possible and the patient reacted
promptly in the ward. At 2.30 p. m. she was
given a blood transfusion. When 250 c.c. had
been given the patient woke up and remarked that
hei heart had stopped beating. She stated that
she felt alright but insisted that her heart had
stopped. Vfe believe that the large amount of
saline was definitely life-saving in this case, and
that if we had stopped the injection when a spe-
cific amount had been given and before return
of the pulse, that she would have died. The pa-
tient’s own observation of the relief of the car-
diac distress due to a low blood volume is also
interesting.
The second case is one of those remarkable
recoveries of a patient for whom we hold a most
discouraging prognosis. We acknowledge that
the credit for the recovery of this woman should
be given to the splendid cooperation of our con-
sultants on the medical side. This patient had
all the classical symptoms and signs of fibroids
and pus .tubes, with a hemglobin of 30% and a
mitral stenosis which was compensated. She was
given a transfusion of 6 00 c.c. whole blood from
which she had a very severe reaction. Rest in
bed, tonics, general hygienic measures and a
blood transfusion brought her hemoglobin up to
50%. Although she was still a poor risk we decid-
ed to operate. What we found was considerably
more than we had expected. The omentum was
adherent to the front of the uterus, the bladder
and the anterior surface of the broad ligaments.
The broad ligaments were markedly edematous.
The tubes were densely adherent to the ovaries
and to the posterior surface of the broad liga-
ments, and contained pus. The uterus was ap-
proximately 12 cm. in diameter and studded witn
small fibroids. Between the fibroids the uterus
was soft and fluctuating; having the consistency
of a pregnant uterus with fibroids in its wall.
When the omentum was released by blunt dis-
section a small amount of colon bacillus pus was
found beneath each adhesion. As the patient
was doing poorly any sort of radical operation
was out of the question. Most of the adhesions were
released so that a drain could be put in the cul-
de-sac. A stab wound was made in one of the
fluctuating areas of the uterus and enlarged radi-
cally by the finger. A large amount of colon
bacillus pus flowed out of numerous pockets in
the uterine wall. The cavity of the uterus did
not seem to be a part of the abscess cavity. Two
cigarette drains were placed in the cul-de-sac and
a rubber tube in the uterus.
For 2 days this woman had no pulse at the
wrist, her extremities were cold and her condi-
tion was extremely grave. She was stuporous
and apparently had little pain. On the third day
she developed an appetite which I think saved
her life. After that third day there was never
a day when she could not take a full house-tray.
Several times during convalesenc-e she showed
signs of cardiac failure which were taken care
of by the medical chiefs. When we consider that
this woman had a postoperative hemoglobin of
30%, mitral stenosis, bilateral pus tubes and an
abscessed uterus which were left in her, I believe
that you will agree with us that her recovery was
remarkable.
The last case presents several interesting com-
plications. This was diagnosed fibroids and an
ovarian cyst. Her hemoglobin was 3 0%. A blood
transfusion did little good. The operation was a
supravaginal hysterectomy, right salpingectomy
and left oophorectomy. Part of the ovarian cyst
was so densely adherent in the cul-de-sac that it
seemed a part of the peritoneum. A gauze pack
was placed in the part of the cyst wall that it
was necessary to leave. On the second day after op-
eration she suddenly developed pain in the chest,
especially severe over the heart. The tempera-
ture rose abruptly from 101° to 105°; pulse from
100 to 135; respirations from 20 to 30. Shortly
after this, the patient became markedly stupor-
ous. Embolism was suspected. On examination
Dr. Scanlan found no signs of emboli in the lungs
but a definite pulmonic stenosis and mitral in-
sufficiency. The temperature, pulse and respira-
tory rates gradually returned to normal. On the
tenth day the temperature suddenly rose to-
101.6° and signs of thrombosis developed in the
left leg, which subsided gradually. On the twen-
ty-first day the temperature again rose to 102°
and thrombosis developed in the right leg. She
had no further distress with her heart. In the
light of these later complications it is interesting
to speculate if she did not have a shower of small
emboli in spite of negative physical signs.
Much has been written recently concerning
thrombosis and embolism. In a paper from the
Mayo Clinic it was reported that in a series of
1712 abdominal hysterectomies there were 5 cases
of fatal embolism — 1 .in 342. There are several
factors which seem to predispose to the forma-
tion of thrombi in the veins. It occurs, most
frequently in gynecologic and obstetric operations,
especially those involving the hemorrhoidal and
pampiniform plexuses of veins. Operation per se,
by lowering the blood pressure, slowing the rate
of blood flow, and increasing the leukocytes and
blood platelets, predisposes to this condition. Pa-
tients over-weight, of 40 years or older, seden-
tary habits with evidence of poor circulation, such
as edema of the legs and and varicose veins, seem
especially prone to the formation of thrombi. In-
fection, too, seems to play a major part. Polak
found the incidence of thrombosis and embolism
in 12,000 obstetric and gynecologic cases in his
clinic to be 0.5%. On the other hand it is well
known that patients with high blood pressures,
with very active circulations, seldom suffer from
embolism. Working -on the problem from this
angle, the Mayo Clinic has suggested that efforts
should be made to increase the metabolic ac-
tivity and stimulate the circulation in all patients
who show signs of circulatory weakness. They
prescribe small doses of thyroid extract before
and after operation and believe that they are
lowering the incidence of this very disastrous
complication.
BERGEN COUNTY
Charles Littwin, M.D., Reporter
The- regular meeting of the Bergen County
Medical Society was held Tuesday evening, March
10, at the Hackensack Hospital, 60 members at-
tending, presided over by the, president, Dr.
Joseph R. Morrow.
The minutes of the last meeting and also of the
executive committee meeting were read and ap-
proved.
Dr. Morrow reported that, as a result of the
.registered letters and his own personal telephone
calls to delinquent members, they had all signi-
fied their intention of paying. He asked that
the matter of suspension be laid over.
The advisability of giving up collations was
discussed by Drs. Harryman, H'allett, Levitas,
376
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
Vroom and Littwin. It was the consensus of
opinion that these should not be dispensed with.
Dr. Sarla reported $1631.60 in the checking
account and $981 in the savings account, with all
debts paid.
Dr. Wolowitz reported on the broadcasting over
stations WBMjS and WOR and also stated that the
post-graduate committee would soon have the
details of the course for May.
Dr. Kilts stated that a plan for collections was
being formulated.
The applications of Drs. Joseph A. Rowe, of
Ridgewood; Thomas F. Reid, of Cliffside; and
Ivan A. Mader, of Hackensack, were read. The
following were elected to membership; Drs. J.
Willis Demarest, of Hackensack; Franz Kastler,
of Rutherford; Trevalyn W. Omstead, of West-
wood. The transfer of Dr. Calvin C. F. Bosch,
of Iowa, was approved.
Dr. Snedecor explained the coming Councilor
District Meeting which will be held at the Ori-
tani Club, in Hackensack, on April 29, Hudson,
Passaic and Sussex Counties joining us. The pur-
pose of the meeting and the agenda as listed in
the Bulletin were explained.
Dr. E. P. Essertier gave a very interesting ac-
count of the Child Welfare Conference recently
held in Washington.
Dr. Frederick Bancroft, Director of Surgery at
the Fifth Avenue Hospital, read a paper on
“Thrombosis and Embolism”. (To be published
in the Journal later.)
BURLINGTON COUNTY
Roscius I. Downs, M.D., Reporter
The regular meeting of the Burlington County
Medical Society was held Wednesday afternoon,
March 11, at St. Mary's Guild House, Burlington.
There were 24 members and guests present, with
President Joseph Kuder in the chair. The guests
included Drs. George N. J. Sommer, President of
the State Society; Irwin E. Diebert, of Camden,
and Professor Bryan, of Rutgers University. The
minutes of the previous meeting were read and
approved.
Dr. P. H. Corpening, of Marlton, who was
elected to membership at the last meeting, was
present and signed the Constitution.
An application of Dr. J. George Wagner, of
Delanco, for membership to the society, was read
and referred to the Board of Censors.
The Board of Freeholders will not now pay the
usual medical fee of $5 for commitment of in-
digent applicants to the county asylum until it
is proved that the applicants are destitute. This
has been discussed in several meetings with little
progress. Dr. Tracy was asked to write to the
secretaries of the other societies for their meth-
ods of collecting these fees.
Professor Bryan, Drs. Sommer and Newcomb
presented the program and the advantages for
post-graduate lectures for Burlington County. If
15 men will subscribe a general course of lec-
tures will be given at the hospital at Mt. Holly.
There was immediate response from 14 members
with the possibility of several more, so the above
lectures are assured for Burlington County.
Dr. Newcomb reported that the societies com-
posing the Fourth Councillor District, including
Monmouth, Ocean, Burlington and Camden, will
have a joint meeting in April. This probably
will be an evening meeting at the Pine-tree Inn,
Lakehurst.
D-r. Sommer spoke of the valuable help from
the Woman’s Auxiliary. In Burlington County
Ilygeia was placed in the high school libraries
by the auxiliary.
Dr. Hammell P. Shipps, Chairmah of the Sec-
tion on -Surgery, announced the following scien-
tific program: “Newer Anesthetics and Their Use
in General Medicine”, by Dr. Irwin E. Diebert, of
Camden, and “Office Reduction of Fractures under
Local Infiltration Anesthesia”, by Dr. Hammell
P. Shipps, of Delanco.
Dr. Diebert said the ideal anesthetic has not
been found. Hypnotics are not free of danger. They
must be placed in the blood stream to produce re-
sults. Ethylin gas is the safest of gas anesthetics.
The patient must have a long period of induction
as in ether. Its best use is in surgery of the ex-
tremities and the thyroid gland. Good relaxation
and less bleeding are noted. Ethyl chloride is the
most rapid acting anesthetic and more dangerous
-than chloroform. Somnoform is a similar pro-
duct. Spinal anesthesia is fine for most cases but
not for the nervous type.
Of the common anesthetics the technic of the
rectal use of ether in oil is complicated. The
toxicity of novocain, both used locally and intra-
spinally, is a definite picture. Convulsions or syn-
copy results. It is terrifying but not dangerous.
It is due to the paralysis of the vasomotor system
and not from paralysis of the cardiac or res-
piratory center. This produces relaxation of the
blood vessels. Blood, like water, seeks its own
level. Keeping the head lower than the feet pre-
vents the catastrophe.
Of the newer preparations percaine or new-
percaine was mentioned. Sleep will last from 4
or 5 to 24 hours. These hours of relaxation are
beneficial in cases of fracture of femur. Avertin,
given rectally 15 minutes before an operation,
produces a profound sleep. It is necessary to
supplement this with other anesthetics. There is
no vomiting and the patient needs less attention
after operation. A chemically pure drug is not
possible, however. Pernatin is similar to sodium
amytal. It is made chemically pure and is given
preliminary to ether. Intravenous solution of
sodium amytal is not on the market. It is in-
jected slowly like neoarsphenamin producing
sleep in 3 minutes. Now sodium amytal is given
by mouth before operation. It is given at 9 p.
m. the night before and 6 a. m. before the oper-
ation. Before this 15 gr. of luminal were given
in 2 doses of 7 % gr. each. This is beneficial in
vomiting of pregnancy and alcoholism.
Dr. Shipps’ method of local anesthesia in re-
duction of fractures is an infiltration above and
in gap of fracture with the local anesthetic used.
The technic is as follows: With careful aseptic and
antiseptic preparation the skin, subcutaneous
tissue, muscles (little in muscle) and blood-clot
between the gap of fracture are infiltrated; 20-150
c.c. of V2 % solution of cocain, procain or novo-
cain are used. Wait 15 to 30 minutes and re-
duce the fracture. A marked relaxation is pres-
sent which makes reduction simpler and painless.
It is indicated especially in the aged and debili-
tated and for skull fractures. It is contraindi-
cated in compound fractures and in the presence
of infection. It is a safe procedure in the office.
Following an excellent meal, the meeting ad-
journed to reconvene in May.
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
377
CAMDEN COUNTY
Robert S. Gamon, M.D., Reporter
The regular monthly meeting of the Camden
County Medical Society was held on March 3, 1931,
President W. J. Barrett in the chair.
The chairman of Committee- on Post-Graduate
Instruction for this society reported that courses
would start on Wednesday, April 1, and con-
tinue each successive Wednesday over a period
of 8 weeks. Gloucester County will com-
bine with Camden County in supporting these lec-
tures. The application blanks are now in the
hands of the members of the society.
The Committee of Resolutions presented its
report on the recent death of Dr. John W.
Donges, an honorary member of this society. (See
obituary columns.)
The Scientific Program consisted of 2 excellent
papers. Dr. R. K. Hollinshed, of Gloucester
County, by invitation, rendered a paper on “A
Review of Some of the Recent Literature on An-
gina Pectoris and . Coronary Artery Disease”. The
paper was well received and was discussed by
Drs. Shafer, Goldstein, Browning, Reik and Hol-
linshed. The second paper was given by Dr.
S. Snedecor, of Bergen County, by invitation, on
‘‘Shall the Doctors Advertise?” The speaker’s re-
marks were illustrated with lantern slides. The
paper was discussed by Drs. Reik, Lippincott,' Lee
and Del Duca.
Among the guests from the other societies
were: Dr. H. O. Reik, Editor of the State Journal;
Dr. Tracy, Secretary of Burlington County So-
ciety; Drs. Diverty and Hollinshed, of Gloucester
County.
The meeting was well attended.
ESSEX COUNTY
E. LeRoy V/ood, M. D., Reporter
Dr. George J. Holmes, Director of the Depart-
ment of Health Education of the Newark Public
Schools, was the principal speaker at the meet-
ing of the Essex County Medical Society, held
Thursday evening, March 12, in the auditorium
of the Academy of Medicine, taking for his sub-
ject “What is Medical Inspection of Public School
Children Doing for the Child and for the Physi-
cian?” When Dr. Holmes took office in 1901 his
main work was the detention of infectious and
contagious diseases among the pupils. Now the
work has developed to embrace instruction in
preventive medicine and hygiene. At the present
time emphasis is laid on disease prevention and
on the prevention of bad results of physical de-
fects. The school authorities do not propose to
enter the practitioner’s field of treatment al-
though their work with mental defectives, crip-
ples and undernourished children may verge on
such field. He outlined the development of the
Medical Department of the Public School System,
with its many ramifications through assistant
physicians, consultant specialists, dentists, nurses,
nutritionists, gymnastic instructors, oral hygien-
ists, child guidance specialists, and said that the
objective is complete instruction in conservation
and improvement of health. Dr. Holmes display-
ed charts showing the organization of his de-
partment.
Dr. George T. Palmer, D. P. H., Director of
Division of Research, American Child Health As-
sociation, opened the discussion, saying: There
are 3 clear-cut reasons for medical service in the
schools. In the first place, the state, in compelling
people to send their children to school, is in duty
■bound to furnish reasonable protection against
the hazards of school life; for there are hazards
in going to school. The possibility of contracting
communicable disease is increased when large
numbers of children are brought into close con-
tact. In going to school the preschool child
passes from the shelter of his mother’s wings into
a new world where he must begin to take care
of himself, and schools should do their best to
see that his health is not injured in the process.
The schools need medical advice in planning pro-
tection against the spread of communicable dis-
eases. This means the encouragement of im-
munization against smallpox and diphtheria, close
daily observation of children to detect signs of
disease in their incipiency, and rules on the re-
admittance of children after illness.
In the second place, schools very properly
should protect their investment. If some children
can’t hear the teacher, or see the blackboard, or
are absent a great deal because of colds, and if
some of these conditions can be improved by
medical attention, then it is good business on the
part of the schools to help direct children to
places where corrections can be obtained. It is
certainly proper ffcr the schools to help parents
make children receptive to an education; it saves
the expense of repeated grades and is of definite
service to the child and his family. For children
more severely handicapped, medical advice is
needed in selecting such children as are in need
of special instruction methods. In short, the
schools are justified in establishing some system
of physical and mental appraisal of their pupils.
In the third place, education consists in part
in assisting the child to develop and take care of
himself. Care of health is a proper subject in
the curriculum, as much so as arithmetic. One
of the ways of teaching health preservation is
through the medical examination. If painstak-
ingly done and if the parent is present, the school
physician has the opportunity to convince the
parent and the child that there is something in
the medical examination that will be useful in
later life. If the examination is superficial the
parent and child are quick to detect it. In the
school examination the medical profession is on
exhibit before the school child and his parent.
It is within the school physician’s power to either
make converts to preventive medical service or
to lessen popular faith in this service. I think
that organized medicine has not sufficiently real-
ized the extent to which the kind of a perform-
ance that the physician puts on in the school may
affect medical practice later on.
These 3 uses of medical service are proper
for the schools and are a matter of public in-
terest transcending private interest.
What are the problems of medical service in the
schools? The first is to find physicians who will do
medical inspection for the salaries offered and
who will take the job seriously. The next prob-
lem is administrative — how to deal with children
in the mass. This differs from the work of the
private practitioner who is dealing with indi-
viduals. What can 1 physician, on part-time, do
for 2500 children? His first inclination is to look
for short cuts, for some simple way of reducing
this task to manageable proportions. This is a
perplexing problem; how to reach the children
378
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
that need medical attention without himself
slowly and laboriously examining the whole lot.
Another problem facing the school authorities
is how to get the children, whom the school
physician, after much effort, has discovered as
needing further professional attention, to actually
get this attention. This is a question that has
to do with the parent, the private practitioner
and the public clinics. In some cities, in order
to meet the needs for corrective attention, schools
have established their own corrective clinics.
There may be good reasons for doing this in some
localities. In principle, however, I would say
that the schools should not go beyond the point
•of discovering and referring cases for outside pro-
fessional attention. It would seem much better
policy to depend on the private practitioners and
the hospitals to provide such facilities. But,
in so far as this service cannot be obtained either
because of expense or other reasons, the schools
are tempted to supply this demand. Naturally,
the schools, after efforts to discover physical
handicaps, are anxious to see that such handi-
caps as are correctable do receive proper atten-
tion. This is a problem that organized medicine
ought to help the schools to solve.
How has school medical inspection worked out
in practice ? An enormous number of inspections
and examinations have been made. Many physi-
cians have .given splendid service, with little or
no recompense. But, generally speaking, for the
country as a whole, the school medical inspection
or examination program is inclined to be some-
what sketchy and superficial. Frankly, some of
it is probably worthless, and might better not be
done. Some states require annual medical inspec-
tion of every child. These laws might better be
changed, for they, as much as anything else, are
responsible for superficial work. If to comply with
the law the physician has to inspect every child
annually he is forced to work very fast super-
ficially on each child. He can’t do otherwise.
The schools want a high medical service that
will be educational as well as effective, but they
haven’t been willing to pay the necessary price.
It is difficult to get and hold sufficient competent
physicians to enter and stay with this work long
enough to solve some of the perplexing difficul-
ties. There is no professional prestige for the
physician in such a position unless the physician
is under a health department or a medical in-
stitution and assigned to the school work as part
of his job. It is hard to find men willing to de-
vote their full time to this medical administra-
tion in the school. There is very great opportunity
for improvement in this field.
What has medical inspection done for the child?
In spite of its administrative short comings it
has stirred great numbers of parents to seek
medical advice for their children; people who
probably would never have sought such attention
otherwise. This advice has been sought from the
private practitioner as well as from public clinics.
A note from the school physician started me to
the oculist with my child about 2 years ago.
The net results of medical inspection in terms
of improved national health are difficult to
measure but that benefits have resulted is hardly
disputable.
What has medical inspection done for the prac-
ticing physician? It has increased his practice, it
has opened his eyes to the wide prevalence of
physical handicaps existing even among pre-
school children, and it has turned the more pro-
gressive men back to the medical school for post-
graduate work. In the last few years one of the
medical schools of the middle west has had many
men register for post-graduate work in pedia-
trics and these physicians say that they want ad-
ditional training because their patients are de-
manding a type of service that they are not pre-
pared to give.
How can school medical inspection be improved?
One way is for organized medicine to take a
greater interest in the subject and lend serious
aid in trying to solve some of the difficulties.
Hospital staffs might assign a number for ad-
visory service. One of the most hopeful signs is
the recent meeting of the Medical Section of the
White House Conference, in Washington. Here
were assembled hundreds, of physicians, many
representing different specialties together with
physiologists, anatomists, biometricians, deans of
medical schools, dentists, nurses, hospital social
workers, nutritionists, lexecutives of voluntary
health associations and of official health agencies,
each meeting the other on equal terms, each
recognizing that each group has something to
contribute to the question of health service for
children. It means a great deal when people
recognize the limitations of their own special field
and are willing to contribute their bit to the
solution of problems that need social as well as
medical correction. School medical inspection
can be improved if schools and school medical
officers will keep certain objectives clearly before
them, definitely fix responsibility, and not overstep
the bounds into fields better conducted by others.
It can be improved by repeal of compulsory
annual inspection laws which would entail pro-
hibitive costs if properly carried out and by
schools getting away from the idea of quantitative
service and substituting in its stead service of a
better quality. Service should be extended only as
funds are forthcoming to permit this extension
at no sacrifice of quality.
The relations of the schools to the private prac-
titioners can be improved if extensive programs
involving the practitioners are adopted only after
consulting the organization representing the
practitioners concerned; instead of adopting pro-
grams and then expecting practitioners to fall
into line. The application of medical service to
schools can be improved if foundations will con-
tribute funds for administrative research to help
work out reliable methods and routines, and
scientific ways of measuring results. The height-
weight-age tables have had great vogue in the
schools as a means of picking out under-nourish-
ed children. Recent research has shown us that
underweight is largely due to skeletal variations
such as narrow hips, narrow and shallow chest.
Weight is determined very largely by skeletal
build. The heavy child, as a rule, has a broad
and deep skeletal framework; the lightweight
child a slighter framework. Nutritional status is
better measured in terms of girth and condi-
tion of subcutaneous tissue, and yet an enormous
amount of attention has been showered on under-
weight. We need better methods of discrimi-
nating which children need this special attention.
It is frequently said that medical knowledge is
20 years ahead of the application of this knowl-
edge. I am inclined to doubt this in the field
of school health work. I have a feeling that prac-
tice is catching up, if it is not getting well ahead
of knowledge; that some things are being done
for which there is very inadequate justification.
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
379
Research is needed to bring scientific knowledge
abreast of current practice.
I have tabulated the results of a survey of
the use of medical and dental service for pre-
school children in 146 cities of the country. The
results came from inquiries at the individual
homes of 140,000 children under 6 years of age.
These surveys were carried out during the past
8 months under direction of the Medical Section
of the White House Conference on Child Health
and Protection. This inquiry covers 4 types of
service — health examinations, dental examina-
tions, vaccination and immunization. Six New
Jersey cities are included. In the average city
the proportion of children under 6 years of age
who at some time in their lives have had a health
examination — while well — is 48%. The percentage
in Newark was 49, or just above the average. East
Orange was 71%, Trenton 67%, Elizabeth 51%,
Passaic 40% and .Camden 32%. In Newark only
3% of preschool children have had a dental
health examination; 19% have been vaccinated,
and 23% immunized.
These figures for Camden were, 32% health ex-
amination, 3% dental examination, 13% vaccin-
ated, 5% immunized. For Elizabeth, 51% health
examination, 5% dental examination, 12% vaccin-
ated, 23% immunized. For Trenton, 67% health
examination, 7% dental examination, 27% vac-
cinated, 10% immunized. For East Orange, 71%
health examination, 22% dental examination, 24%
vaccinated, 36% immunized.
No city of our state was included in the groups
of the 5 cities ranking highest among the 146
cities in each of 4 health measures.
Dr. Henry C. Barkhorn, President of the Essex
County Medical Society, then introduced Miss
Janet M. Geister, R. N., Director at Headquarters,
American Nurses Association, who spoke on the
subject “Nursing Mr. Middle-Man’r and reviewed
some of the present day economic problems of
organized nursing. The high cost of sickness is
attracting considerable attention and the middle
class family with limited means finds difficulty
paying a day and night nurse $7 each, plus board,
for any length of time. Miss Geister said that
this per diem charge could not be reduced by the
nurse because she only has work 8 months each
year and is only paid for 7, and she must be al-
ways available. Miss Geister suggested as reme-
dies part-time nursing in the home according to
the needs of the patient, and staff nursing in the
hospitals, giving the patient only the amount of
actual special nursing he needs and charging him
proportionately, saving him from paying for the
nurse’s idle periods.
Drs. M. Weinstock Bergman, Giovanni Fasano,
and. Nicholas L. Pollis, all of Newark, were elected
members of the society.
Eye, Ear, Nose and Throat Section
Academy of Medicine of Northern New Jersey
E. LeRoy Wood, M.D., Secretary
Dr. J. Wallace Hurff, Chairman of the Eye,
Ear, Nose and Throat Section of the Academy of
Medicine, devoted the meeting held Monday eve-
ning, March 9, to reports of interesting cases.
Dr. B. M. Hawley, of New Brunswick, reported
a case of “Mastoiditis wi,th Complications”. J. M.,
colored, aged 34, came to see me on September 23,
1 9 30, suffering with suppurative otitis media on
the right side. His trouble began 3 weeks pre-
viously following a cold for which he had been
treated by his family doctor. Severe pains had
been with him for about 48 hours. Paracentesis
was done at once, with immediate relief and a
free flow of pus. I saw him 2 days later when
the discharge was very profuse and he was feel-
ing very well. A week later his family doctor
phoned me that he had a chill, but otherwise was
all right. I advised his removal to the hospital
for an x-ray examination and observation. In-
stead of going to the hospital he called at my of-
fice saying that he was feeling well excepting for
a severe headache. Examination showed no dis-
charge in the canal; drum membrane was red-
dened and suggestive of pus or infection still
there; absolutely no pain on pressure over the
mastoid.
X-ray examination showed mastoiditis with
most of the trouble in the attic. At operation
on October 6 the mastoid was found badly in-
fected; pus was plentiful from the attic to the
tip; lateral sinus was uncovered showing an in-
fective thrombosis. The sinus clot was removed
and the wound packed with iodoform gauze. He
was discharged from the hospital in a week, hav-
ing run a perfectly normal temperature from the
day of operation. He came to the office for his
mastoid dressings and about October 28 com-
plained of some headache, which became more
severe the next day, and on the following morning
at 2 a. m. I received a telephone call stating that
the man was unconscious. I ordered his removal to
the hospital and saw him about 7 a. m. when he
was absolutely unconscious; pupils moderately
dilated, and a slight stiffness of the neck. Spinal
puncture was done; the fluid was cloudy. The old
wound being re-opened and cleaned out, the sinus
held a clot but no free pus was found until a
probe was passed through the dura in the region
of the sinus. This was opened wider and con-
siderable pus escaped. A probe passed into this
abscess cavity about 1 % in., so an iodoform
gauze drain was inserted and the rest of the
wound packed. The Wassermann had been nega-
tive, but he acknowledged a specific infection
acquired 7 years before, and for which he had
received treatment. In spite of negative Wasser-
mann I felt that his previous syphilitic state had
something to do with the present sickness, and
gave him on the day of operation an injection of
sulpharsphenamin. It looked very much as if
the man was going to die and I did not think the
injection would do any harm. The next day the
patient was very much better, answering ques-
tions and understanding most everything that was
said to him.
Pus obtained from brain abscess and cultures
of the spinal fluid J>oth showed the Friedlander
bacillus.
The patient showed steady improvement com-
plaining mostly of weakness in the legs, not being
able to walk very far, and at the end of 4 weeks
he was discharged from the hospital and 3 weeks
later went back to work. The question, that I
would like to present to you is — -“Do you think the
sulpharsphenamin did any good or was it a
useless effort?” Personally, I think it did good.
Examination of records shows that infection of
the meninges by the Friedlander bacillus is rare
and that when such infection occurs it is gen-
erally fatal; there being only 2 or 3 authentic re-
coveries on record.
Dr Nathan Zvaifler, of Newark, reported 3 cases
380
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
from the Beth Israel Ear, Nose, and Throat Ser-
vice.
Case 1. M. S., first seen in the clinic with diag-
nosis of left optic atrophy, cause unknown. Ex-
amination was negative except for a deflected
septum and hypertrophied middle turbinates; the
left antrum was slightly cloudy but irrigations
were negative. Radiogram of the sinuses reveal-
ed no further pathology. He was admitted to the
hospital and a submucous resection and double
turbinectomy were done. The operation was per-
formed with no special difficulty and nose was
packed with vaselin gauze. Next day at 8 a. m.,
about half of packing was removed; temperature
100.2°; patient had no complaints. At 10 a. m.
complained of headache, 'which became pro-
gressively worse, and by 3 p. m. he was very
restless, slightly irrational, and picked the re-
maining packing from his nose. Temperature at
this time was 102.6°. At 9 p. m. he was delirious;
temperature 103°; stiff neck and suspicious Ker-
nig. Lumbar puncture revealed a cloudy fluid
under pressure; reported later to be pneu-
mococcus type 4. Blood culture done at same
time showed the same organism. Lumbar punc-
tures were done twice daily. ; he also received
some antipneumococcus serum. Condition became
steadily worse and Dr. Barkhorn and I did a
wide decompression for frontal head sepsis. The
frontal sinus showed hyperplastic mucous mem-
brane from which the pneumococcus was obtain-
ed on culture; there was no bony erosion nor any
localization of the process revealed in our wide
exposure.
Autopsy did not disclose clearly any route of in-
fection from nose to brain and we thought most
likely that the meningitis and abscess were sec-
ondary to a septicemia caused by osteothrombo-
phlebitis of one of the smaller veins.
Case 2. J. T., 3 years old, was admitted to the
hospital with diagnosis of meningitis. The his-
tory went back 3 weeks to a sore throat with tem-
perature of 102° in the morning and in the even-
ing normal. On December 27, about 10 days be-
fore admission, a swelling was noticed on back of
left thigh. Both father and mother were syphil-
itic and the child had a -)- 2 Wassermann. Ex-
amination showed a swelling of the left thigh and
a suspicious Kernig; no stiff neck; no abnormal
reflexes; temperature 101.5°. Lumbar puncture
showed fluid under marked pressure and about
30 c.c. were removed. Examination of the fluid
at this time was entirely negative except for posi-
tive Wassermann and Kahn. Immediately after
the lumbar puncture the child shot a temperature
of 105° and on this date the pediatrician noticed
a red ear drum on the right side. The child daily
became worse and another lumbar puncture was
done which showed markedly cloudy fluid with 380
white cells to the field, and on smear streptococcus
hemolyticus; at that same time the ear was bulg-
ing. I saw the child and advised an immediate
mastoid operation, which was done the same
evening. Mastoid was completely necrotic and a
wide exposure of the dura and sinus was made.
The child did badly and died 2 days later.
Autopsy examination and review of the his-
tory led to the conclusion that the cerebral con-
dition and the abscess of the thigh were secondary
(the latter metastatic) to infection of the blood
stream from otitis media at the time of the re-
ported sore throat.
Case 3. Child, J. S., with history of having as-
pirated a pin 1 year before and been for past few
months treated by various physicians for a per-
sistent cough. Finally, one day she coughed up
what appeared to be part of a pin. X-rays showed
rest of pin in the left lower bronchus. In New
Y’ork she was bronchoscoped unsuccessfully and
came back to Newark. That night she suddenly
developed a severe pain in the chest with cyanosis
and rapid respirations, and was brought to the
hospital where diagnosis of traumatic pneumo-
thorax was made. Radiogram revealed a com-
pletely collapsed lung with pin in the lower
left bronchus and an infection of the pleural cav-
ity. It seemed inadvisable, and was probably im-
possible, to reach the foreign body through a
bronchoscope with the lung in that condition, and
a thoractomy was done to relieve the empyema.
The lung failed to expand and she had a per-
sistent fistula from the operation with a thick-
ening of the pleura and an encapsulated empyema.
In January of this year, 3 months later, she sud-
denly coughed out the rest of the pin from the
collapsed lung, in spite of the fact that it had
been collapsed for 4 months or more. She was
recently operated on again to break up the ad-
hesions in the pleural cavity and to drain the re-
maining collection of pus.
Dr. James B. Shannon A, of Montclair, reported a
case of “Brain Abscess with Pneumococcal Menin-
gitis and Recovery. May 9, 1930, P. P„ male,
aged 19, admitted to Mountainside Hospital on
the service of Drs. Richardson and Moore, with
a provisional diagnosis of bilateral chronic mas-
toiditis complicated by intracranial extension. His-
tory of discharge from both ears for 17 years;
some transient pain in ears and headache since
1917. Three days prior to admission, developed in-
tense pain over the right mastoid region, which
became progressively more intense. Day before
admission had a chill, followed by high tempera-
ture, mental depression, unbearable headache and
vomiting.
On admission, temperature was 105°, pulse 100;
W. B. C., 16,100; 82% polymorphonuclears. Spinal
fluid cloudy and under increased pressure (no
manometer reading made); 8400 cells per c.c.
Positive pneumococcus smears; and cultures
showed pneumococcus, type 4. Blood Wasser-
mann 4 + . Radiograph showed infantile sclerotic
mastoids with no detail; far forward sinus.
Patient was very listless but could be aroused,
moaning with pain. When strenuously aroused,
cerebration was slew, but patient seemed tran-
siently oriented. No motor aphasia. Pupils- small,
sluggish; right larger than left. No nystagmus.
No paralysis. Hyperemia of left fundus. Blur-
ring of right disc. Foul discharge from both
ears, more profuse from right. Tenderness
over both mastoids, more pronounced on right.
Canal on right side boggy, obscuring view of
drum. Left drum depressed; high attic erosion
with cavitation, containing cholesteatomatous ma-
terial. Hearing loud voice at auricle. Marked re-
traction of head, with rigidity of neck, which
could not be overcome. Good coordination con-
sidering patient’s lethargic state. No clonus,
geniculars absent. Positive Oppenheim and
Babinski.
A few hours after admission a right radical
mastoidectomy was done; the sinus exposed and
examined, appeared normal; middle fossa ex-
posed and dura found covered with unhealthy
granulation tissue. Incised and more than 2 oz.
of thick, foul pus evacuated from a large en-
cysted temperosphenoidal abscess cavity. Drain-
age with soft rubber dam; wound packed open
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
381
around drain. Culture from mastoid and ab-
scess cavities showed pneumococcus.
The following 6 days presented a rather stormy
period, patient having to be kept under restraint,
irrational, garrulous, and taking off bandage.
Spinal taps were carried out twice daily with
difficulty. There was a progressive decrease in
cell count in subsequent specimens of spinal fluid.
The last positive pneumococcic culture was ob-
tained 4 days after operation. Temperature
ranged from 100°to 104.6°; pulse 60-100. On the
seventh day postoperative the temperature and
pulse returned to practically normal and remained
so.
Six weeks after the initial operation a sec-
ondary flap and closure operation was done. The
radical cavity being packed with iodoform gauze
around the wick of rubber dam, draining the ab-
scess cavity. Drain permanently removed 2 weeks
later and patient discharged to out-patient de-
partment. Complete healing of radical cavity 10
days after discharge.'
I do not consider this an unusual case, nor a
permanent recovery. A recent review of some 5 0
brain abscess cases of otitic origin, with varying
degrees of meningitis, reminds me our bubble of
elation over apparent success is all too often
ruptured at a subsequent autopsy.
In the case of this patient, I feel that the future
is very uncertain; a potentially dangerous ear
needing operation, for which he has not, been
willing to give consent; an established syphilitic
infection; an encysted chronic temperosphenoidal
abscess, which has not been obliterated and which
may or may not be sterile; and some residual
signs of encephalitis. At least no meddlesome
surgery has been done to date. What the even-
tualities of the future may be, I am not *prepared
to say.
Dr. Lyndon A. Peer, of Newark, reported “Plastic
Repair After Radical Frontal Sinus Operation and
2 Cases of Rhinoplasty’’. The first case which I am
presenting tonight is that of a young girl who
came to the City Hospital 1 % yr. ago with an
acute left frontal sinusitis. The sinus was oper-
ated on externally and free drainage given into
the nose and outside over the brow. Improved
slowly for 2 weeks and then began to have fronto-
occipital headache, chills and a high temperature.
A second operation was performed in which a
large portion of the frontal bone adjacent to the
left frontal sinus, including the inner plate of the
sinus and entire brow, had to be removed in order
to reach healthy bone. The wound was left
wide open, exposing the dura. The patient left
the hospital 2 months later cured of her
osteomyelitis, but there remained a wide scar in
the forehead closely adherent to the dura and a
deep depression over the left brow. As the young
lady was very sensitive about her deformity I
performed a plastic operation. The scar first had
to be removed carefully from the external sur-
face of the dura. I then rotated the deeper tis-
sues so as to fill in the depression and approxi-
mate the skin edges. As you may see by com-
paring her present appearance with this photo-
graph taken before operation, she has a very
satisfactory result.
Case 2. This patient had a hump over the bony
bridge of her nose which caused it to appear
twisted to the right. The line of the dorsum of
the nose exclusive of the hump was straight and
all that the patient required was removal of the
hump. This was accomplished through an alar
incision in the vestibule to prevent an external
scar. In these cases it is best to remove the
periosteum first before chiseling off the bone, and
if a groove remains it is necessary ,to refracture
the nasal processes and squeeze the bone together
to fill in the groove.
Case 3. An examination of the original photo-
graph taken before operation shows the bony
bridge displaced to the left and a saddle in the re-
gion of the cartilagenous bridge. A submucous re-
section had been performed 15 years ago, but the
cartilage support remaining was twisted to the
left and prevented setting the bones in a mid-
plane. It was first necessary to remove part of this
obstructive cartilage bar. The bones were then
fractured and set in correct position and the sad-
dle filled with strips of lower lateral cartilage
taken from the alar regions and transferred to
fill out the depression.
Dr. Henry C. Barkhorn, of Newark, reported 3
cases of “Head Sepsis’’. He discussed the path-
ways of infection in intracranial sepsis, describ-
ing a case of pia-arachnoid abscess from the
frontal sinus, a temperosphenoidal brain abscess
from the ear, and a meningitis from the petrous
tip and labyrinth, to illustrate anterior, middle
and posterior fossal types.
Dr. Dennis F. O’Connor read the report of the
Nominating Committee, which was composed of
Drs. Elbert S. Sherman, Chairman, Dennis F.
O’Connor and Henry C. Barkhorn, naming for the
new officers: Chairman, Dr. C. W. Buvinger; Sec-
retary, E. LeRoy Wood.
There were 40 present, and the meeting ad-
journed at 10.45 p. m.
Academy of Medicine of Northern New Jersey
E. LeRoy Wood, M.D., Reporter
The Annual Meeting — and Twentieth Anniver-
sary— of the Academy was held at 91 Lincoln
Park, Newark, Thursday evening, March 19.
The Nominating Committee recommended for
consideration the following list of officers: Presi-
dent, Wells P. Eagleton; First Vice-President, F.
DuBois Bunting; Second Vice-President, Walter
B. Mount; Secretary, Adrian R. Kristeller; Treas-
urer, Henry C. Barkhorn; Trustee, John F. Hag-
erty; Library Committee, Frank W. Pinneo; Cor-
responding Secretary, Harvey Herald; Committee
on Admission, B. E. Failing.
Dr. H. J. F. Wallhauser, Chairman of the Nom-
inating Committee, paid tribute to Dr. Newman,
who has served as Secretary of the Academy more
than 15 years. He suggested the position of
Secretary Emeritus, be created for Dr. Newman
and this was done.
Speakers at the meeting were Ferdinand Pe-
cora, former assistant district attorney of New
York County, and Prosecutor Joseph L. Smith, of
Essex County. Mr. Smith declared an undesir-
able tendency on the part of the public to criticize
public officials has sprung up recently.
Mr. Smith paid tribute to Dr. Harrison S.
Martland, chief Essex County Medical Examiner,
as “the greatest member of his profession in the
county and one of the greatest aids we have in
the prosecution of many criminal cases”.
Mr. Pecora, speaking on “Social Responsibility
for Crime”, declared the legal profession, as lead-
ers in the "handling of crime, could learn a lesson
from medical practice in this work. He pointed
382
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
out that physicians have come to realize the
value of preventive medicine and have developed
health codes and practice to prevent epidemics,
in addition to the usual curative procedure and
quarantine measures after disease appears.
“The legal profession has done too much legis-
lating, given too much attention to penal laws,
spent too much time dealing with the criminal,
the diseased person. It has not given enough at-
tention to the social agencies that can eradicate
crime, that can eradicate conditions which breed
crime germs and convert otherwise healthy boys
and girls into criminals.
It is better to prevent the making of criminals
than to deal with them afterward.’’
The former New York prosecutor pointed out
that criminals every year are appearing in
younger groups. He declared the solution to
crime must be found in training of the young
either by their parents or otherwise. “Stricter
laws”, he said, “have deterred professional crim-
inals from continuance of crimes of violence, but
have not stopped the making of young gangsters.”
Mr. Pecora attacked the growing complication
of law, declaring legislatures “have been tinker-
ing with the penal law continually for more than
a century”.
“In the penal code of New York”, he said:
“There are dozens of sections devoted to the crime
of larceny. The student of law must read
hundreds and hundreds of pages of judicial opin-
ions also in order to understand the law on lar-
ceny. The same is true in regard to homicide or
perjury or any other felony.
And yet each of these 3 could be summed
up in one of those older laws, so much simpler,
so much plainer. Larceny law is no more than
a development of 'Thou shalt not steal’. The
others, too — homicide — ‘Thou shalt not kill’, per-
jury— ‘Thou shalt not bear false witness.’ How
much simpler this is, how much wiser.”
The Academy of Medicine of Northern New Jersey
Ralph Kristeller, D.D.S., Assistant Secretary
At the twentieth anniversary meeting, Dr. Er-
win Reissman entertained the Honorable Fer-
dinand Pecora who was the essayist of the even-
ing.
Honorable Ferdinand Pecora presented a new
outlook to many of us, especially as to the close
relationship between our relative professions.
He stated that the legal profession would do well
to follow our example of finding the cause for the
disease rather than the cure for the one already
afflicted. In summarizing his lecture he went
back to the Ten Commandments, saying that
much legal phraseology and interpretation could
be condensed to “Thou shalt not kill”, “Thou
shalt not steal”, and “Thou shalt not bear false
witness”. If these were taught more diligently
in the home, all children of tender years would
understand their meaning.
Prosecutor Smith was called from the audience
to deliver a short address.
Prior to the former assistant district attorney’s
talk, the Chairman of the Nominating Committee,
Dr. J. H. F. Wallhauser, read his report. For
President, Wells P. Eagleton; Vice-President, P.
DuBois Punting; Corresponding Secretary, Har-
vey Herald; Secretary, Adrian Ralph Kristeller,
D. D. S.; Treasurer, Henry C. Barkhorn; all
the above nominated for the term of 2 years.
Trustees for 5 years, E. Reissman, J. F. Hag-
erty; Committee cn admission for 3 years, B.
E. Failing; Library Committee for 3 years, H. R.
Livingood.
Following this he paid a most glowing tribute
to the efforts of Dr. E. D. Newman, who for the
past 18 years has held the post of Recording Sec-
retary, and by resolution favored creating the
post of Secretary Emeritus, which was passed
unanimously. He then nominated Dr. E. D. New-
man for the position which report was greeted
with tremendous applause.
The past year has been one of very great pro-
gress in the annals of the Academy of Medicine.
Dr. Reissman has achieved the distinction of
■having large audiences at the stated meetings.
He has had as his guests essayists from far and
near, even going so far as Montreal in quest of
them.
During the present regime, many beneficial
changes have been made in the building of the
Academy. Two plaques have been erected in ap-
preciation of gifts previously given, one to the
Dean of the Newark Medical Profession, Dr. E.
.1. Ill, and the other in memory of Dr. William
Disbrow.
GLOUCESTER COUNTY
Henry B. Diverty, M.D., Reporter
An especially interesting session of the Glou-
cester County Medical Society was enjoyed at
the Country Club, Thursday evening, March 19.
Dr. Thomas C. iStellwagen, professor at the
Jefferson Medical College, took for his subject
“Some Phases of Genito-Urinary Surgery of In-
terest to the Genera] Practitioner”. Dr. George J.
Mullershon, a former resident of this community,
also spoke.
Lectures concerning the post-graduate courses
in cardiac diseases and gastro-enterology to be
conducted by the Medical Society of New Jer-
sey, in cooperation with the Rutgers University
of New Brunswick, were discussed at great
length. The course will start Wednesday, April
1, at the Camden Dispensary, 729 Federal Street,
The Educational Committee from Camden and
Gloucester Counties includes Drs. A. H. Lippin-
cott, Benjamin F. Buzby, Paul Mecray, Thomas
K. Lewis, of Camden; R. K. Hollinshed, West-
ville; H. B. Diverty, Woodbury; and S. F. Ash-
craft, of Mullica Hill.
Those attending the meeting were: Drs. I. W.
Knight, W. J. Burkett, J. Harris Underwood, O.
R. Wood, James Hunter, Jr., A. B. Black, Dun-
can Campbell, Ralph Hollinshed, E. E. Downs,
Harry Nelson, Paul Pegau, H. W. Stout, C. I.
Ulmer, and H. B. Diverty.
Guests included Drs. Corson, of Bridgetown;
Reik, of Alantic City, Editor of the State Medi-
cal Journal; Casselman, of Camden, and Church,
of Salem.
HUDSON COUNTY
E. G. Waters, M.D., Reporter
The monthly meeting of the Hudson County
Medical Society was held at the Carteret Club,
Jersey City, March 3.
The paper of the evening was by Dr. Wells P.
Eagleton, of Newark, who spoke on “Complica-
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
383
t;ons of Cranial Injuries”. The first part of the
paper was accompanied by a lantern slide demon-
stration in comparative anatomy of the central
nervous system, with especial reference to pro-
gression of the higher centers and retrogression
of the olfactory areas in the ascending scale of
development. The presentation was enhanced by
Dr. Eagleton's charming personal observations of
developmental changes of special importance, and
of many of the physiologic experiments marking
mile-stones in our understanding of what are now
accepted as facts.
Dr. Eagleton then discussed fractures of the
frontal and temporal regions of the head, con-
trasted with regard to their resistance to infection,
and the effects of direct trauma. Fractures of the
frontal region are of importance because of the
anatomic configuration which permits the rapidly
growing mucous membrane of the nose and air
sinuses to invade a rent in the dura before the
latter has had a chance to grow. Thus, when the
dura has been broken, or the -blood sinuses in-
volved in a frontal fracture, there is an excellent
chance for either immediate or late infection.
The patient may apparently recover, yet die
months later when he contracts a head cold, the
infective organisms of which invade the brain
via the mucous membranal tract laid down long
before. When the dura is not broken, there is
seldom danger from this source. Fractures in the
temporal region present quite another problem.
Here, the dura, less intimately adherent to the
bone, is less frequently torn by a fracture. Also
there is no rapidly growing epithelial surface to
invade the fracture line, as the area is well cov-
ered by the temporal muscle and fascia. But here
we have something else of importance. The mid-
dle meningeal artery courses this region and is
usually involved in linear fractures. When it is
torn, it is unable to retract as most arteries do,
for it is firmly held by the dura, and bleeding con-
tinues. Dr. Eagleton stressed repeatedly the so
well known but so easily forgotten “free inter-
val” symptom of this type of fracture, where the
patient gets up after the injury, and subsequently
becomes unconscious as the accumulating sub-
dural blood causes increasing intracranial pres-
sure with progressive embarrassment of the vital
■centers. This type of fracture requires imme-
diate operation to save the patient’s life. Its
treatment is quite in contrast with other types of
fracture, where the fracture is unimportant, the
cerebral trauma being the important and unfor-
tunately irremediable factor.
Dr. Eagleton talked on fractures involving the
auditory apparatus, emphasizing the necessity of
not interfering or washing out the ear, lest a bad
condition be made worse by inducing infection.
Slides depicting various types of skull frac-
tures with their all-important attendant brain in-
jury were shown. After all, a fracture is nothing,
unless brain injury accompanies it. And when
the brain -is injured, no man may say how or
when the patient will recover, for permanent
changes all too frequently follow.
Dr. Eagleton discussed at some length the
medicolegal difficulties encountered in defining
the effect of brain trauma, which effects are often
profound without having any serious objective
findings. When he concluded, many questions
were asked and a lively discussion brought out
many points of practical interest and stressed
many of those which had been mentioned in the
presentation.
Clinical Society of North Hudson Hospital
J. Africano, M.D., Reporter
The regular monthly meeting of the Clinical
Society was held Tuesday, March 10, with Dr.
Pellegrino D’Acierno acting as chairman; 52
members and guests were present. Dr. Tannert
read the hospital report for February: 195 ad-
missions; 244 discharges, 17 deaths, of which 5
were medical, 5 surgical, 1 new-born, 1 E. E. N.
& T., and 5 pediatric; 4 autopsies were performed.
D-rs. Klaus and Pcarlstein discussed plans for
the Annual Staff Dinner to be held on Wednesday,
March 25, at 9 p. m., at the Paramount Grill,
New York City.
Dr. Klaus discussed the death of a patient with
final diagnosis of ileocecal intussusception and
edema of the lungs. A male child, aged 5 V2,
complained on the first day of abdominal pains,
vomited on the second day, and had more severe
colicky pains on the third, when he was admitted
to the hospital, February 22. There was tender-
ness in the R. L. Q., with some rigidity and
-slight distension; temp. 102°; W. B. C. 13,000;
polys, 80%. The picture was that of acute ap-
pendicitis. Dr. Losche suggested Intussusception
when he did a rectal examination and believed he
felt a mass, but there were no gastro-intestinal
symptoms except the vomiting — no diarrhea or
bloody stool. At operation an intussusception of
the ileocecal type was found, the ileum entering
with the valve into the cecum for a distance of
8 in.; the bowel itself was not gangrenous; how-
ever, the appendix was kinked and bound down
by adhesions, and intensely inflamed. It was re-
moved because so severely diseased, and the in-
tussusception reduced. The child developed a
distended abdomen and expired on the fourth day
postoperatively, from paralytic ileus. Dr. Klaus
felt that this child should have gotten well, and
emphasized certain points regarding the surgical
aspects of intussusception, gleaned from exper-
ience and not often referred to in text-books: the
surgical treatment usually consists of reduction
of the intussusception, thus restoring the con-
tinuity of the bqwel; if the intestine is gan-
grenous, a resection is indicated, but these are
bad subjects for such a procedure; an intus-
susception is one of the most disastrous catas-
trophies in a child, analagous to perforated gas-
tric ulcer or to acute pancreatitis in an adult; the
appendix is practically in all cases found to be
congested, edematous, and 2-3 times the normal
size—actually it is part of the same condition,
i. e., secondary to the intussusception, and there-
fore it should not be removed, as the ligature is
apt to blow off from relief of the edema; regard-
ing the question of recurrence in the same pa-
tient, after recovery, there are no cases on record;
immediately after reduction the parts are so ede-
matous and swollen that they could not possibly
telescope into each other again; in the case of
adults sometimes an intussusception forms from
a polypoid tumor of the intestine — a recurrence
here would be in the form of intestinal obstruc-
tion from angulation or adhesions.
Dr. Luippold stated that this case impressed him
with the difficulty of diagnosis of the acute ab-
domen in the child; the patient gave a fairly
typical history and signs of appendicitis, and yet
at operation 2 conditions were found present,
either of which presumably might have been
primary.
Dr. Tannert brought up the question of mobile
384
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
cecum, sometimes found in these cases; it is
claimed by one author that in the ileocolic type,
unless the ligaments are shortened at operation,
there may be a recurrence of the intussusception.
Dr. Schuhnan asked concerning an enterostomy
— not done in this case because there was only
slight distension pre-operatively.
Dr. W. Braunstein gave the pathologic findings
in the appendix: peri-appendicitis confined to the
serosa, without involvement of the mucosa and
lumen; regarding recurrence, he stated that theo-
retically it might happen; often an intussusception
is found postmortem, but without signs of con-
gestion.
Dr. William Braunstein reported a case of
“Spontaneous Pneumothorax". M.H., male, aged 26,
onset of present illness 5 weeks before admis-
sion, when the patient noticed that he was be-
coming short of breath, particularly after slight
exertion. At the same time he began to complain
of a cough which he attributed to an ordinary
cold. He also became conscious of a rapid heart
beat after slight exertion or excitement. These sym-
toms continued without any marked progression.
In addition, he complained of hoarseness for
several weeks before admission, and the cougn
had become productive of yellowish material, but
there was no hemoptysis. The family history
was negative to tuberculosis. His parents, 6
brothers and 3 sisters, were living and well.
The past history showed the usual children’s
diseases, measles and mumps. Venereal diseases
denied. Surgical history negative. Weight was
128 lb. as compared to 135 lb. 1 year ago.
The essential findings were in the chest; heart
was not displaced but the sounds were very
rapid; no murmurs; right upper chest anteriorly
ind posteriorly gave a slightly tympanitic per-
cussion note; left upper was dull; right axillary
space dull; tactile and vocal fremitus increased
over the right upper but breath sounds slightly
diminished and respiration gave a definite me-
tallic sound; the left upper and middle right, an-
teriorily and posteriorily, presented patches of
bronchial breathing and numerous persistent
rales. At times there was amphoric breathing in
the right upper chest. The abdomen and ex-
tremities were not remarkable except for clubbing
of the fingers.
Roentgenogram of the chest revealed a pneu-
mothorax of the upper right anterior lobe; inter-
lobular band radiographed; infiltration of the
middle right lobe; fibrosis of the upper left lobe
with cavitation; heart and mediastinum normal.
Sputum positive for tubercle bacilli on 2 occas-
ions. Blood count: Hb., 78%; R. B. C., 4,540,-
000; W. B. C„ 10,500; P. 76; L. 24. Urine and
Wassermann negative.
The patient had an up and down temperature
varying between 99° and 100° a. m. and 102°
and 104° p. m. Pulse varied between 100 and
140. Respirations 25 to 40. Blood pressure
102/68. Shortly after the diagnosis was made,
arrangements were made for transfer to Laurel
Hill.
Dr. Braunstein explained the x-ray findings, the
signs of pneumothorax being quite evident; there
was no effusion.
Dr. Pearlstein said that dyspnea had been pres-
ent for a long time, and that the ultimate prog-
nosis was grave from the standpoint of chronic
pulmonary tuberculosis; ' he cited an article in a
recent issue of the Jour. A. M. A., in which a
similar case is discussed.
Dr. Justin pointed out that while the pneumo-
thorax was on the right side, the lung involve-
ment was on the left, hence it appeared that the
perforation was of long standing, an attempt
perhaps of nature to rest the lung on the same
principle we resort to in creating an artificial
pneumothorax. The physical signs were not
typical of pneumothorax, but could have been
due to a large-sized cavity.
Dr. Luippold discussed the etiology: The com-
monest cause is tuberculosis of the lung, from
rupture of a cavity or a caseous focus in acute
phthisis; he considered Dr. Justin’s hypothesis of
nature’s attempt to rest the lung quite plausible,
but it occurs also in an active tuberculous process,
and most times by an accidental perforation
of the pleura.
Dr. S. Africano suggested changing the title of
diagnosis to read “Chronic Pulmonary Tuber-
culosis Complicated by Pneumothorax’’ to differ-
entiate the spontaneous type.
Dr. S. Braunstein. “Ulcerative Colitis”. F. D.,
male, aged 41, usual occupation bar-tender, at
present iron worker, was admitted to ward on
January 20, 1931, with the chief complaints of
swelling of right leg and ankle, dyspnea, and
pain across the back. For the past week he has
noticed bright red blood in his stool. Had a
marked pallor of the face and mucous mem-
branes. Heart markedly enlarged in all of its di-
ameters; soft blowing systolic murmur with max-
imum intensity over the apex, transmitted up-
ward to the axilla; also a rough systolic
over the aortic area transmitted to the right nipple.
The rhythm is regular and the sounds of fair
quality. The liver palpable midway between the
umbilicus and the right costal margin; not ten-
der nor nodular. Spleen also enlarged and easily
palpated. No ascites; no palpable masses. Rectal
examination showed several soft internal hemor-
rhoids.
Roentgenogram of chest showed the heart en-
larged in all diameters. Gastric series was re-
ported as “ulcerative colitis of the descending
colon".
The striking features of this case are the
marked anemia, profuse rectal bleeding, enlarged
liver with a smooth edge, markedly enlarged
spleen, enlarged cardia with murmurs, and x-ray
findings of colitis. We feel that we can account
for the clinical manifestations of this patient on
the basis of cirrhosis. The marked anemia is of
secondary type and is due to bleeding from the
hemorrhoids. We do not feel that there is
any ulceration of the bowel in the nature of a
non-specific ulcerative colitiis because all the
symptoms of colitis are missing. There may,
however, be a solitary ulceration on the basis of
venous engorgement, of the same etiologic factor
as the hemorrhoidal bleeding, which is secondary
to portal obstruction.
Treatment in this case was a bland diet and
rest in bed. He also received 2 transfusions which
brought his hemoglobin up for a few days but
due to his profuse rectal bleeding, it was at one
time as low as 19%, with a relative decrease
in red cells. He has had dilute HC1 and calcium
lactate and his blood picture has improved, the
Hb. on March 10 being 41%, but prognosis is
poor.
Dr. Green had considered a diagnosis of throm-
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
385
bocytopenia, but this was ruled out when
the platelet count was persistently a low normal.
Dr. Justin first saw this puzzling case on his
service in January, when he had 20% hemo-
globin, an enlarged heart and a bloated appear-
ance pointing to an acute Bright’s disease; the
history, however, pointed to cirrhosis, and the
findings up to this time place him as a case of
hypertrophic cirrhosis more definitely.
Dr. Stein believed that a cardiac origin of a
chronic passive congestion of the liver should be
considered the probable diagnosis till proved
otherwise.
Dr. S. Braunstein, in closing, stated that Hanot’s
type of biliary hypertrophic cirrhosis was ruled
out on the basis of no fever jaundice, early as-
cites, and the negative history of biliary or other
infectious diseases, and that the absence of gas-
tric or intestinal symptoms did not rule out cir-
rhosis.
Atypical Pneumonia — 2 Cases
Dr. Tidivell reported 2 “Cases of Atypical Pneu-
monia’’. A. P., an infant 7 months of age, ad-
mitted to the hospital in what appeared to be a
moribund condition. Feeding was from the
breast, and recently cooked cereals had been
added to the diet. Orange juice or cod-liver oil
had not been given. Had been perfectly well
until 4 days before admission, when a dry cough
was noticed; this became persistently worse and
2 days later was accompanied by fever and cya-
nosis. The urinary output was diminished at this
time. On the fourth day of illness the child be-
came much worst; dyspnea and cyanosis were
marked and he had been in coma for several
hours before being brought to the hospital.
On percussion, the chest revealed dullness in
the right base posteriorly, where crepitant rfiles
were heard, accompanied by bronchial breathing.
Mucous rales were heard throughout the chest,
amounting almost to a pulmonary edema. The
heart sounds were normal but rapid. Temperature
101.4°; pulse 144; respirations 20 and of the
Cheyne-Stokes’ variety.
Inhalation of oxygen was instituted and 1/300
gr. of atropin sulphate given for 3 doses. Lum-
bar puncture was performed and 35 c.c. clear
fluid obtained under marked pressure. Two hours
later the child seemed to react and cried con-
siderably. Next morning the character of breath-
ing was much improved. Temp. 102.8°; P. 160;
R. 60. He seemed to be aware of his surround-
ings and followed objects. As the fontanelle was
still bulging, another spinal puncture was done
and 18 c.c. of fluid removed under 14 mm. Hg.
pressure. The chest findings remained about the
same, with the exception of possibly fewer crepi-
tant rales. Lumbar puncture was done on the
next 2 days, the first under 20 mm. pressure and
the last at 10 mm. From this time on there was
no more bulging of the fontanelle. The spinal
fluid was negative, as was the Wassermann.
The x-ray report on admission was negative.
The day before dischai’ge, both upper lobes re-
ported as hazy.
On February 13, 10 days after admission, tem-
perature rose to 104° and next day the left ear
drum was found to be 'bulging. Double para-
centesis was performed and followed by a pro-
fuse discharge of pus from the left. ear. Within
3 days temperature reached normal and remain-
ed so until he was discharged as cured on Feb-
ruary 20.
Case 2. K. K., a male infant, 16 months of age,
admitted to the hospital February 6, 1931, with
fever, cough and irritability.
He had no convulsions nor muscular twitch-
ing, but a discrete macular rash was noted on
the chest.
In the chest there were scattered mucous r sties
with some dullness in the right base; a blowing
systolic murmur heard at apex of the heart. Tem-
perature, 104°; pulse, 168; resp. 64.
This picture continued not much changed ‘or
6 days, when the temperature dropped suddenly
from 104.6° to 99° and the child seemed improved.
However, the next day it was noticed that there
was some neck rigidity, Brudzinsky positive but
negative Kernig. Temperature again rose to 104°.
Lumbar puncture was- done but no fluid obtained.
This was repeated the next day with similar re-
sults. A tap on the following day yielded a few
drops of clear fluid, which was negative on cul-
ture. Twelve days after admission the child
started to vomit; the character was not pro-
jectile, but continued once or twice a day. Two
weeks after admission there was still dullness,
crepitant rales and bronchial breathing in the
right base. X-ray of the chest showed nothing
significant. The Mantoux test was negative. At
this stage he appeared quite drowsy, and it was
felt that we were dealing with an encephalitis.
On February 22, the left patellar reflex was
absent. The next day a tap was again attempted
and 5 c.c. of slightly viscid, yellowish fluid was
removed under decreased pressure. Examination
of this fluid was unsatisfactory. February 25 a
cisternal puncture was performed and 12 c.c. of
cloudy fluid removed under pressure. The cell
count was 10,200; no organisms were seen in the
smear. After a few hours, culture showed definite
meningococci. Antimeningococcic serum (15 c.c.)
was given by the cisternal route. The general
condition became much worse, and in spite of
stimulation the child expired. Autopsy was re-
fused. ■
Final diagnosis was bronchopneumonia com-
plicated by meningococcic meningitis with sub-
arachnoid block.
Dr. Stein stated that these cases were interest-
ing from the standpoint of cerebral manifesta-
tions; the first suffered from a temporary men-
ingismus and coma, and was relieved by spinal
tap; in the second case there appeared to be an
independent infection of the cerebrospinal sys-
tem, with blockage, so that repeated attempts at
relief of spinal pressure failed in both cases;
the pulmonary signs were marked enough but
the radiographs did not bear them out.
Dr. Bailyn saw the second patient on the out-
side, and described the events leading up to his
order of hospitalization — beginning with slight
fever, cough and few chest signs on the first day,
he found the child in coma on the second day
with lungs so full of rales that the heart sounds
were inaudible, and a trismus of the oral cavity
prevented a throat examination; later in the day
cyanosis supervened and the cerebral symptoms
became more manifest; a spinal tap was attempt-
ed at the home before removal to the hospital.
Dr. J. M. Stein. “Chronic Vaginitis with Acute
Pyelitis in Infant.’’ V. L., aged 11, admitted Feb-
ruary 12, with the complaints of dysuria, chills
and fever, headache, anorexia and offensive
vaginal discharge. For the past 3 years has had
an offensive vaginal discharge; treated by various
386
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
physicians, using permanganate douches with
temporary relief.
Three days before admission, patient com-
plained of pain in the right side of the abdomen
and nausea. The following day she vomited and
complained of dysuria. Following a douche she
had a considerable flow of blood from the vagina;
the following morning similar hemorrhage.
The only significant finding was a positive
Murphy sign on the right side. Temp. 105°.
Laboratory findings — Blood count: Hb. 70%;
R. B. C., 3,900,000; W. B. C., 8800; P. 67; L.
33. Urine: Many large clumps of W. B. C.
Patient had an irregular fever with peaks at
104-105° and with remissions and occasional in-
termissions. The longest period of normal tem-
perature was from Mai-ch 3 to 7, but next day
the temperature rose to 106°. On March 10 tem-
perature dropped to normal again.
On March 3, 1931, Dr. Hekimian made a cys-
toscopic examination; the bladder and ureteral
orifices were normal; catheterized urine of the
right kidney contained a few white cells; it was
sterile on culture. Report of pyelogram; right
pelvis normal in shape; calyces distorted and
pressed to the midline; right ureter dilated; no
evidence of stone; right kidney not outlined.
On March 6 the urine contained a large amount
of albumin (16%) and many R. B. C. Examina-
tion of vaginal ulcer scraping showed an acid-
fast bacillus; could not be determined whether
it was smegma or tubercle. A guinea-pig was in-
oculated for accurate determination. The Wasser-
mann and von Pirquet tests were negative.
Treatment for the vaginitis was daily swabbing
with 10% argyrol. Response was good. At this
time there is no discharge. The ulcers have
healed. Treatment for the pyelitis was not so
satisfactory. She was on a restricted diet and
potassium citrate. On March 6 she showed evi-
dence of a pyelonephritis.
The interesting features of this case are: The
chronic vaginitis which probably was the cause
of an ascending infection and subsequent pyelo-
nephritis. Severity of the disease is rather un-
usual. Anorexia was a marked feature during
the entire course.
Dr. Hekimian did the cystoscopy and saw large
flakes of pus welling around in the bladdei
cavity; culture proved to be sterile; he suggested
methylene blue for treatment.
Dr. Tidwell concluded that not enough alkali
had been given the patient, from a comparison of
the urinary findings with the temperature curve;
it was found that 15 gr. every 4 hr. caused only
a partial drop in temperature, while on complete
omission of alkali the fever rose to 106°; when
readministered the fever remitted to normal; the
vaginitis is cured, while the nephritis still per-
sists, and on the latter the prognosis of the cases
hinges.
Dr. Kolb saw this patient in private practice
before admission to the hospital, and considered
possible ulcerative tuberculous vaginitis, or some
yeast infection; the von Pirquet was negative.
Dr. Pcarlstein mentioned as another possibility
the presence of an infection due to an organism
similar to the spirochete of trench-mouth dis-
ease, which thrives in an alkaline medium.
Dr. Lulppold suggested a means of differentia-
tion between the smegma and the tubercle bacil-
lus by prolonged immersion in acid-alcohol; in
case of the smegma bacillus the carbol-fuchsin
would eventually fade away, while the acid-fast
organism would hold the stain indefinitely.
Dr. Kooperman has found that a low leukocyte
count does not mitigate against a diagnosis oi
pyelitis; the reaction of the urine per se does
not determine the absence or presence of infec-
tion, but if the urine is alkaline the patient is
more prone to infection.
Dr. Hekimian reported an “Interesting Case of
Hematuria’’. The presence of blood in the urine,
either microscopic or macroscopic, may be due
to lesion of the genito-urinary tract, systemic
condition, or pathology of organs in close ana-
tomic relation to the tract. Among the systemic
causes are blood diseases, such as leukemia, hemo-
philia, polycythemia, Hodgkin’s disease, purpura,
analine dye poisoning. High protein diet ana
physical exertion may give rise to temporary
hematuria.
Acute lesions of the appendix, female adnexa or
colon can be responsible for traces of blood in
the urine. Although the method of transmission
of infection from adjacent organs to the urinary
tract by continuity is a possiblity, the usual chan-
nel is by the lymphatics. Blood in a specimen
of urine in a case of suspected acute appendicitis
needs investigation to rule out a coexisting path-
ology. Hematuria as precarious menstruation
and from tumors of the adrenals has been re-
ported.
Of all hematurias, 75% are due to lesions of
the genito-urinary tract, and 70% of these are
found in the upper urinary tract. Establishment
of diagnosis of conditions involving the bladder
and urethra is comparatively easy, because these
parts are brought under direct vision by the aid
of the cystoscope and urethroscope. However,
the same is not true in case of the kidneys and
ureters, because the method is an indirect one; it
depends upon the visualization of an opaque
medium in the tract. Variations in outline of
normal renal pelvis, irregularity of the outline
due to blood clots and exudates may easily lead
to erroneous diagnosis. Consequently, repeated
complete urologic examinations may be necessary
to arrive at a correct conclusion.
The following case is of interest from a diag-
nostic standpoint: W. C., male, aged 41, truck
driver, admitted with the complaints of weakness,
generalized pains, epigastric pain, bloody stools,
hematuria, urgency, dysuria and frequency of 4
months’ duration. Past history: Gonorrhea at 17
and 34; gonorrheal arthritis with the last infec-
tion. Operated upon for repeated hemorrhages
from gastric ulcer, 7 yr. ago.
The patient was kept under observation for a
week. Laboratory findings: Blood count: Hb.,
65%; R. B. C., 4,000,000; W. B. C., 6000; P., 60.
Wassermann negative. Urine, daily specimens:
alkaline, bright red or smoky with blood; sugar
negative; albumin from trace up to 14% by
volume; phosphates; and R. B. C. Of course
blood will give an albumin reaction, but on later
dates albumin was still reported when there was
no blood. X-ray was negative for calculi.
First attempt at cystoscopy was unsuccessful
on account of the marked irritability of the ure-
thra. He came under my care a week later.
There was no visible discharge; external geni-
talia negative; first .urine blood-tinged; prostate
and seminal vesicles congested and extremely
tender; moderate amount of debris after mas-
sage. A small observation cystoscope was intro-
duced into the bladder after passing several stric-
April, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
387
tures of the anterior urethra. Bladder mucous
membrane normal; no growth; no blood observed
from the ureters; posterior urethra deeply con-
gested and bleeding.
The urinary symptoms continued, and 3 days
later ureteral catheterization was done under
spinal anesthesia. A jet of blood was seen from the
left ureter. Pyelography on that side showed no
abnormality; catheterized specimens were found
sterile on culture.
He was transferred to the Urologic Service
with the medical diagnoses of grippe, chronic
gastric ulcer, chronic cholecystitis and chronic
glomerular nephritis. Urinary symptoms were re-
lieved with medication of methylene blue and
prostatic massage. To date there has been no
recurrence of hematuria or urinary distress.
The tource of hematuria in this case was from
2 different areas. Observation showed some of
the specimens contained blood only at the start
of the stream, the rest of the flow being clear.
The origin of this was at the posterior urethra,
as confirmed by cystoscopic examination, result-
ing from chronic prostatitis and vesiculitis and
further aggravated by strictures of the anterior
urethra. Most of the specimens with smoky hue
were of renal origin, most likely due to glomer-
ular circulatory disturbance. The possibility of
fibrous or angiomatous change in one of the renal
papilla must be kept in mind.
Dr. Tataryan related a case of “Hyperemesis
Gravidarum’’. The essential cause of liyper-
emesis gravidarum is toxemia, although in cer-
tain cases neurosis and reflex excitability are
strongly in evidence. No satisfactory distinction
can be made between toxemic and neurotic vom-
iting as the neurotic states more frequently re-
sult from than cause hyperemesis. A disturbance
of the carbohydrate metabolism is a common
feature. The toxins originate from the fetus or
from endocrine dysfunction or focal infection
in the mother. There is profound necrosis of the
central portion of the lobules in the liver; and
in fatal cases, the liver undergoes fatty degenera-
tion.
N. B., female, aged 28, gravida iii, para i, ad-
mitted to hospital on August 3, 1930; state of
gestation 2 months. She had pleurisy in 1928;
pernicious vomiting through her first pregnancy,
giving birth to a living child; vomiting in second
pregnancy, which ended in spontaneous miscar-
riage in the third month of gestation. One month
before admission she started to vomit; at first only
in the mornings, then after each meal, and finally
20-30 times a day. Tenderness all over the ab-
domen, more marked near the umbilicus. Blood
pressure 175/70. Urinalysis negative except for
acetone and diacetic acid. Blood count: Hb.,
80%; W. B. C., 6300; P., 50; L., 49; M., 1. Blood
chemistry; NPN, 54 mgm.; creatinin, 1.9; sugar,
60; urea, 20; carbon dioxide, 60.
The usual treatment was instituted but no im-
provement was noticed for the first 5 days, so
on the sixth day cystoscopy was done, which
revealed moderate congestion of the trigone,
some trabeculation, apparently normal ureteral
orifices. The right ureter was easily catheterized;
the urine cloudy and microscopically revealed
W. B. C. free and in clumps, some R. B. C., and
staphylococcus on culture. After catheterization
she showed marked improvement; did not vomit
for 6 days and was discharged as cured. Follow-
up: After her discharge, she was very comfort-
able except occasional emesis through the preg-
nancy until full term.
Comment. In hyper emesis gravidarum, if the
patient does not respond favorably to the routine
treatments within a week, cystoscopic examina-
tion should be done to determine the possibility
of a symptomless pyelitis, regardless of the urin-
ary findings. It should be done early in order
to prevent an active pyelitis, as this complication
will make the prognosis much graver. In patients
suffering from hyperemesis in repeated preg-
nancies, ad interim, the condition of the kidney
pelvis and ureters should be carefully investl-
ated.
Dr. Kolb referred to Duncan’s work on this
form of toxemia. He regards all cases as po-
tentially pernicious and uses emenin, an en-
docrine product which he claims acts as a spe-
cific, and concludes that some condition of the
mother prevents the formation of an antitoxin
to circulate in the maternal blood to overcome
the normally formed toxins of pregnancy, so
that the vomiting is progressive; whereas the
emenin supplies this deficit.
Dr. D’Acierno emphasized that all cases of vom-
iting of pregnancy are not amenable to treat-
ment in the same manner, and advised that, be-
sides the taking of a careful history and doing a
detailed physical examination, stress should be
placed on the following 5 points:
(1) The neurotic element: many cases will re-
spond solely to rest in bed; isolation, good nurs-
ing, and a mild sedative like luminal gr. 2 by
hypodermic injection 2-3 times a day, or simply
by chloral 10 gr. daily by rectum.
(2) The reflex element: for practical purposes
this should not be disregarded, as in some cases
the vomiting is actually terminated by replacing
a retroverted uterus, or by the cure of a rectocele
by pessary.
(3) The endocrine factor: Hirst, of Phila-
delphia, still advocates corpus luteum as the
drug choice; others recommend thyroid extract,
or pituitary and parathyroid in more intractable
cases.
(4) Coincident focal infections: not only teeth
and tonsils but also a latent sinus infection, or a
pyelitis, cystitis or pyelonephritis, may be the
original toxic focus; Poliak of the Austrian school
designates 98% of the vomiting of pregnancy pa-
tients to this class.
(5) The most important, the factor of meta-
bolism, and conveniently divided into 3 stages:
(a) The dehydration stage: as a result of
vomiting, water is lost to the maternal organism,
and this may be made up by the injection of glu-
cose solution, Titus using up to 3 liters, or 3000 c.c.
of a 3% solution, daily, either subcutanteously
under the breasts or by intravenous infusion; if
gotten early, this may tide the patient over in 1
or 2 weeks.
(to) The starvation stage: if severe vomiting
still persists for over 2-3 weeks, there results de-
struction of serum proteins; this destruction may
be counteracted by the intramuscular injection
of phosphoplasmin-lecithin solution; 75%, in Dr.
D’Acierno’s experience, react favorably and per-
manently to this treatment. He suggested trans-
fusion in this stage, though he has not tried it.
(c) The stage of hepatic degeneration, as shown
by bilirubin in the urine, a positive immediate
direct Van den Berg, and the other increasing
signs of toxemia which may finally end in coma;
no case should be allowed to reach this stage;
Van Wyck is using lately a continuous phlebocly-
388
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
sis adjusted at about COO c.c. per hour o£ a 3%
solution, for 5 hours daily; also a high caloric
diet is being advised in the form of duodenal
feeding, as 3 oz. each of skimmed milk and 10%
glucose; finally, when no improvement occurs in
this stage after 4-5 days under intensive treat-
ment, the uterus must be emptied.
MERGER COUNT Y
A. Dunbar Hutchinson, M.D., Reporter
The Mercer County Medical Society met in the
Carteret Club on the evening of March 11, Presi-
dent Swern presiding.
Dr. I. W. Held, of New York, delivered an ad-
dress on “Modern Conception of Jaundice and
its Clinical Treatment”, giving a detailed account
of numerous laboratory analyses attending arti-
ficial production of the several constituents found
in the blood stream during a period of jaundice.
The various methods employed in differential
diagnosis of jaundice were specifically defined,
and the determined manner in which Dr. Held
expressed himself proclaimed his thorough ac-
quaintance with this subject.
Dr. H. D. Rellis was elected an annual dele-
gate in the place of Dr. M. W. Reddan, who, by
virtue of his office, is a member of the House of
Delegates.
Dr. Harry J. Majeski was elected to associate
membership in the society.
MIDDLESEX COUNTY
Samuel Gordon Berkow, M.D., Reporter
The regular meeting of the Middlesex County
Medical Society was held March 25, 9 p. m„ at
the Perth Amboy City Hospital, Dr. William H.
McCormick presiding.
Drs. George N. J. Sommer and Henry O. Reik
were welcomed by the president, who expressed
the pleasure of the society in the visit of these
distinguished guests.
Drs. Irwin, of Matawan; Alexander Fishkoff,
of Perth Amboy, and Dieker, of South River, were
voted to membership. The application of Dr.
Rothfuss, of Woodbridge, was referred to the
Membership Committee.
Dr. M. S. Goldberger, of Mount Sinai Hospital,
New York City, read a paper on the “Ascheim-
Zondek Test for Pregnancy”. Of 368 tests, correct
results were obtained in 95%. This is slightly
less than Ascheim and Zondek’s figures, which
show 98.6% correct results, but is a higher per-
centage of efficiency than is claimed for the
Wassermann test in the diagnosis of syphilis.
Dr. Goldberger cited 2 cases of chorio-epi-
thclioma in males, in which female sex hormone
was obtained from the blood.
Dr. Morrell, Director of Endocrine Research at
Squibb’s Laboratories, New Brunswick, opened
the discussion. He inquired as to the efficiency
of a pure pituitary preparation in producing a
positive skin reaction on injection intradermally,
and as to the nature of the cases in which the
Ascheim-Zondek would be of clinical value.
Dr. Sommer spoke on urine tests for pregnancy
as carried out on his surgical service. He stated
his high regard for the methods elaborated by
Frank and his co-workers.
employed by the County Society in acting upon
applications for membership and stressed the
necessity of abiding by the by-laws which have
been adopted by the State Society. He then called
attention to the value of an active Woman’s Aux-
iliary to the county society, which can be in-
termediary between the society and the public; it
can influence legislators; it promotes better un-
derstanding between physicians.
Dr. Reik spoke entertainingly and informatively
on various subjects important to the members of
the society. He spoke of the Journal and its
many features, including original articles, scien-
tific data, and reports of scientific meetings; and
its pages devoted to medical economics, esthetics
and forensic medicine; he urged the members to
read the Journal for information vital to their
welfare. He scored the endorsement of cigarettes
and cigars by physicians and health officers.
Rising vote of thanks was tendered to Drs.
Sommer, Reik, Goldberger and Morrell.
Medical Section of Rutgers Club
February Meeting
John H. Rowland, M.D., Secretary
Regular meeting of the Medical Section of the
Rutgers Club was held on Thursday evening, Feb-
ruary 26, at the Campus Tea Room. Dr. Klein pre-
siding, with 32 members, friends and guests
present.
There being no business to transact, the speaker
of the evening was immediately introduced. Dr.
Walter Dannreuther, Director of the Department
of Gynecology at the Post-Graduate Hospital, New
York, spoke on “Diagnosis and Treatment of
Local Infection of the Uterus and Adnexa”, pre-
senting his topic interestingly with aid of lantern
slides. He stressed particularly the modes of in-
fection, demonstrating the lymph channels and
other paths of infection, and differential diag-
nosis, and also the difference between good sur-
gical judgment and bad practice. The paper was
discussed freely by members.
After the meeting the members adjourned to
the porch dining room where they were enter-
tained by Drs. Klein, King, Leonard and Mer-
rill.
March 6 Meeting
The regular monthly meeting was held Friday
evening, March 6, at the Campus Tea Room,
where about 35 members, friends and guests were
present; Dr. William Klein presiding.
Dr. John Morehead, of the Post-Graduate Hos-
pital, New York, spoke on the subject of “Trau-
matic Injuries", cautioning against mistakes in
injuries particularly of the head, back, pelvis and
knee joints, where external appearance or super-
ficial examination wrould not suggest any serious
trouble.
Dr. Morehead spoke of wounds with particular
relation to disinfection, suturing, drainage, dress-
ings, and tetanus antitoxin; also of wounds that
that were already infected, and stressed treatment
in early, intermediate and late stages of infection,
with indications for treatment. He also referred
to injuries to the joint, particularly synovitis and
dislocations, stressing early recognition, prompt
reduction, retention and early motion, and return
to function.
The paper was discussed by many of the mem-
bers, to the advantage of all.
April. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
After the meeting the members adjourned to
the porch dining room, where they were enter-
tained by Drs. McGovern, McKiernan, Nieman,
and Nafey.
March 20 Meeting
The annual meeting of the Medical- Section of
the Rutgers Club was held on Friday evening,
March 20, at the office of Dr. Howley, Dr. William
Klein presiding. There were 15 members present.
The minutes of the previous meeting were read
and approved.
Reports of Committees: Dr. Faulkingham, in
the absence of Dr. Merrill, Chairman of the Audit-
ing Committee, reported on the auditing of the
books of the Treasurer up to February 6, 1931.
Committee on Visiting Nurses: In the absence
of Dr. McGovern, Chairman, Dr. Johnson report-
ed that the committee met with Miss McLeod, of
the Visiting Nurses’ Association, and discussed
the efficiency of nursing and cooperation of physi-
cians. It was moved by Dr. Johnson, and passed,
that the Secretary be instructed to write a letter
to the Visiting Nurses’ Association commending
the good work they are carrying on.
Application for membership to the Club from
Dr. Tilton was read. Resignation of Dr. King
was accepted.
At this point Dr. Nafey brought up the ques-
tion of closed meetings for members only. Refer-
ence was made to Article III of the Constitution
which covers that point.
Applications for membership of Drs. Rona,
Chester T. Brown and Marshall Smith were voted
upon. Drs. Brown and Smith were voted in as
members of the Club.
There being no other new business, the members
proceeded to the election of officers for the en-
suing year. Dr. Howley, Chairman of the Nom-
inating Committee, read the nominations of Dr.
Johnson for Chairman, Dr. Gutmann, Vice-Chair-
man, and Dr. Rowland, Secretary and Treasurer.
A motion was made and passed that the nomina-
tions be closed, and that the Secretary cast a
ballot for the election of the above-named officers.
Next, a report was made by the Treasurer up
to March 20, 1931.
At this point Dr. Klein thanked the various
members of Committees and others who aided in
making this past year so successful.
Dr. Nafey made a motion that a vote of thanks
be given Dr. Klein for his excellent services dur-
ing the past year and for the refreshments about
to be served. On motion the meeting adjourned.
MONMOUTH COUNTY
William H. Von Oehsen, M.D., Reporter
The February meeting of the Monmouth County
Medical Society was held at the Berkeley-Carteret
Hotel, Asbury- Park, Wednesday evening, Febru-
ary 25, with Dr. William K. Campbell presiding.
Communications were read and ordered filed.
A letter was read from Dr. Henry O. Reik.
Executive Secretary of the State Society, asking
for information as to historic data our 'society
may possess which would be of use to the His-
torian. On a motion from Dr. G. V. Warner, of
Red Bank, seconded by Dr. H. Brown, of Free-
hold, the Secretary is ordered to let Dr. Reik
know that the minutes of this society are avail-
able since the date of its organization in 1816
and are now in possession of Dr. Warner, who
389
is writing a history of the medical profession in
Monmouth County.
Dr, Warner also moved that the minute book
dating from 1885 to the present time be bound.
Motion seconded by Dr. Brown and carried. Dr,
Brown was appointed by the President to take
charge of the binding.
Application of Drs. Woronoff, Matthews and
Niemtzow, for membership, were referred to the
Board of Censors.
Dr. Frank Altschul, reporting for the Radio
Committee, said a list of subjects was to be made
from which those members who have not already
broadcast will have an opportunity of selecting a
subject and arranging for a date. It was also
moved and seconded that a record be made of the
talks which have already been given and incor-
porated in the minutes. Dr. Altschul was also
asked to try to find out the reaction of the pub-
lic to these talks and whether there have been
any letters or questions sent in which would help
us arrange a program.
The Committee on Education reported that
those men who were interviewed regarding the
Post-Graduate Course were mostly opposed to en-
rolling.
Dr. Fisher, of the Program Committee for the
coming State Society Convention, gave a brief re-
sume of the meeting held in Trenton to arrange
the different features of the program.
Mr. William Couse, President of the Asbury
Park Trust Company, gave a very interesting talk
on the “business and economic side of the practice
of medicine”, which brought forth some lively
discussion.
Dr. James Fisher read a paper discussing the
same subject from the doctor’s point of view.
This was also very well received.
A buffet lunch was served.
MORRIS COUNTY
Marcus A. Curry, M.D., Reporter
A regular quarterly meeting of the Morris
County Medical Society was held the evening of
Thursday, March 12, at the Elks’ Club in Dover.
President Sutphen presided over an attendance
of about 45 members and guests.
Routine business was suspended to give oppor-
tunity to insurance representatives to present
their propositions. Mr. Heard, of Hornblower &
Heard, Newark, explained concisely a policy to
cover the physician against all claims for mal-
practice, except criminal acts, at a low rate; and
recommending it for consideration by any physi-
cian not already covered or not adequately cov-
ered; and expressing a willingness to have a rep-
resentative call at the physician’s office to ex-
plain the contract further. The society was ad-
dressed also by a representative of other com-
panies affording protection against other than
malpractice: the Manufacturers’ Casualty Insur-
ance Company of Philadelphia, writing automo-
bile insurance, liability, property damage, col-
lision and fire, at special low rates: also explain-
ing a life policy, a special contract to members of
the medical profession; the Commonwealth Cas-
ualty Company, a Pennsylvania concern, with a
contract specially written up in conference with
Dr. Pinneo, of Essex County.
Minutes were read and approved, including
the proceedings of the- Executive Committee, the
390
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
April, 1931
i
latter Indicating that Drs. Costello and Plume will
report on the death of Dr. Adsit. Favorable men-
tion was made of the first annual meeting of the
First Councilor District, at the Academy of Medi-
cine in Newark, February 12.
Drs. Campbell and Horn were reported as
dropped for non-payment of dues, in accordance
with the by-laws.
Treasurer Emory reported a balance of $1202.28,
and that 5 members have not as yet paid their
clues for 1931.
Dr. Ruth Ferris, of Morristown, was duly pro-
posed for membership, the proposal taking the
usual course.
To prepare a roster of officers for the ensuing
year, to be submitted at the June quarterly meet-
ing and voted on at the annual meeting in Sep-
tember, the following Nominating Committee was
duly appointed: Drs. Young, Frost and Costello.
The scientific chapter of the meeting was a
symposium on “Asthma’’ by Dr. Lathrope and
his confreres, who read the following papers:
“Some Difficulties of the Asthma Problem’’, Dr.
George H. Lathrope; “Allergic and Bacterial
Phases’’, Dr. Royce Paddock; “The Role of Focal
Infection in Asthma”, Dr. Lyndon A. Peer.
The papers (promised for Journal publication!
indicated careful and painstaking preparation and
elicited an unusual degree of interest, and con-
tributed to making this meeting live up to the
high standard that has been set in past years
for the Dover meeting. The papers were widely
discussed by Drs. Costello, Krauss, Spencer,
Haven, Plume, Matthews, F. Grendon Reed,
Pinckney, Julia Mutchler, and Howard S. Hatch,
Resident Physician of the Morris County Tuber-
culosis Hospital and Tuberculosis Specialist at
the New Jersey State Hospital at Greystone Park.
After adjournment refreshments were enjoyed
in the club dining rooms.
PASSAIC COUNTY
Wayne W. Hall, M.D., Secretary
The regular meeting of the Passaic County
Medical Society was held at the Passaic City
Club, Passaic, March 12, with Dr. Carlisle pre-
siding. There were about 100 members present.
The minutes of the February meeting were ap-
proved as read.
The Board of Censors presented its report to
the society. This report contained the approval
of the applications of the following doctors: Al-
bert S. Irving, Radburn; M. G. Joelson, 122 Pater-
son Street, Paterson; and James M. Allen, 657
Main Avenue, Passaic.
A discussion was held as to the question of ad-
mission to the society of physicians doing con-
tract practice. At present this matter is deter-
mined by the local society, although the subject
is now in the hands of a committee of the state
society.
Our society was greatly honored by the pres-
ence of Dr. George Sommer, of Trenton, Presi-
dent of our State Medical Society; Dr. John F.
Hagerty, of Newark, Vice-President of the State
Society; and Dr. Reik, of Atlantic City, Editor of
the Journal.
Dr. Reik gave a report on the progress of the
State Medical Journal, and called attention to
some of its special features. The Executive Office
has available medical movies and a projector
which are offered for the benefit of society pro-
grams.
Dr. ,T. B. Morrison, of Newark, Recording Sec-
retary of the State 3ociety, read a paper on “The
Menace of State Medicine”. He advocates pre-
paredness on the part of the medical profession.
The scientific paper of the evening was pre-
sented by Dr. Royal C. Van Etten, Attending
Gynecologist to the Sloane Hospital, New York
City. His subject was “Modern Obstetric Meth-
ods at Sloane Hospital”, illustrated by slides and
movies.
Adjournment followed a collation.
Obituaries
COLHOUN, Charles, of 24 West Passaic Avenue,
Rutherford, died at his home February 23, 1931, at
the age of 67.
Dr. Colhoun was born in North Carolina, ac-
quired his medical education at the College of
Physicians and Surgeons, Columbia University,
and practiced in Rutherford for 30 years. For 16
years he served as a member of the Rutherford
Board of Health.
DONGES, John W., of 805 Cooper Street, Cam-
den, born of Jacob and Sarah Donges, September
18, 1844, in Strochsburg, Pennsylvania, died Febru-
ary 4, 1931.
Dr. Donges attended Strochsburg Academy and
was graduated in medicine from the University of
Pennsylvania in the Class of 1866. He was a mem-
ber of the Camden City Council, U. S. Pension
Board, Camden Board of Assessors and Camden
Board of Health. He belonged to the Odd Fellows,
Masons and was an Honorary member of the
Camden County Medical Society.
Resolutions on the Death of Dr. Donges Adopted
by Camden County Medical Society
WHEREAS, John W. Donges, a medical prac-
titioner for many years, and a valued member of
the Camden County Medical Society, has left his
earthly labors and passed on. therefore,
BE IT RESOLVED, that in his death the so-
ciety has lost not only a faithful and skilled mem-
ber of the profession, but also a distinguished
representative in the community at large; one who
has added dignity to the profession by earnest
work as a plain citizen, in both peace and war
times. Dr. Donges* entire life, as a man, was
spent in the service of his fellow-men, and spent
unselfishly. He was at the front, and in the line
of fire, when the destines of our National Govern-
ment were at stake, and when peace returned he
served his home community in various positions
in the local government. His example will be
cherished by his fellow practitioners who have
adopted this resolution, and ordered that a copy
be sent to his family.
Alexander MacAlister.
A. Haines Lippincott.
W. H. Pratt.
ERROR IN OFFICIAL LIST
(Letter from Dr. J. B. Morrison.)
To the Editor: Will you kindly insert in the
April issue of the Journal the following note:
Through an error in the office of the Treasurer
of the Cumberland County Medical Society, the
name of Dr. H. Garrett Miller was omitted from
the list sent in for publication in the “Official
List” of members of the Medical Society of New
Jersey. Dr. Miller is and has always been in good
standing-
391
journal of The Medical Society of New J ersey
Under the Direction
of the Committee on Publication
Vol. XXVIII., No. 5
ORANGE, N. J., MAY, 1931
Subscription, $3.00 per Year
Single Copies. 30 Cents
PREVENTING THE TRANSMISSION OF
SYPHILIS BY CONTROL OF IN-
FECTIOUSNESS*
John H. Stokes, M.D.,
Philadelphia, Pa.
The United States Public Health Service
lias recently released, as reasonably trust-
worthy, an estimate of nearly 500,000 new
infections with syphilis annually in the United
States ; and irrespective of its cost in dis-
ability, syphilis has varied in different esti-
mates, between first and fourth place among
the causes of death in man, since Osier’s re-
vision of British mortality statistics. Syphilis
is now definitely known to lead tuberculosis
and scarlet fever in incidence ; it is reported
one-third more frequently than diphtheria, 3
times as frequently as small-pox, 5 times as
frequently as typhoid fever; 600,000 patients
with it are constantly under medical care in
this country, an estimate which takes no ac-
count at all of the enormous number of latent
infections for the moment neither under ob-
servation nor treatment. What more im-
portant subject could a medical society choose
for consideration, in the face of these facts,
than this — in very truth the critical health
problem of the present day. The prevention
of syphilis is not only important in itself, but
it is important because the past 2 decades of
medical history with respect to it have been
a sovereign illustration of fundamental max-
ims in the control of disease in general as a
♦(Read at the Passaic County Medical Society
meeting, Dec. 10, 1930.)
public health problem. At one and the same
moment (and the fact is one of deep concern
to us as individual medical practitioners), the
syphilis problem is significant because it fur-
nishes the ideal illustration of the value of
controlling infectiousness chemotherapeuti-
cally by germ-destroying drugs, and also is the
outstanding example of the greater effective-,
ness of state as compared with individual ef-
fort in the suppression of disease. Through
socialized effort, directed at the control of
infectiousness, the incidence of new infections
with syphilis has apparently decreased since
1919, 5/6 in Great Britain, 2/3 in Germany,
and 9/10 in Belgium. From France, whose
individualism of medical practice compares
with our own, and whose incidence of syphilis
is, at least for the time being, on the increase,
comes evidence as to the reasons for the con-
trast. An individualistic system for the con-
trol of an infectious disease lacks a coordinat-
ing force, a program control through central
authority which follows through a plan of at-
tack without regard to temperamental vagary,
individual notions based on negligible exper-
ience, therapeutic impressionism, prejudices,
self-interest and the activities of the pharma-
ceutic detail man. France and, to some ex-
tent, this country suffer from ailments with
respect to the treatment of syphilis which
Jeanselme and Brunier have clearly enumer-
ated ; a disposition to substitute bismuth for
the arsphenamins ; non-recognition of the in-
fectiousness of syphilis in the woman; aban-
donment by both private physician and pa-
tient of all treatment as soon as signs disap-
pear; the tendency of the practitioner to try
new fads in both diagnosis and treatment;
392
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
and, among special influences of a social and
economic character, an increase in prostitution
and an influx of foreign labor. This country,
in which, in contrast with the larger part of
the Old World, 2/3 to 4/5 of all syphilis is
in the hands of the practitioner, may well con-
sider the maxim — “whom the shoe fits, let
him wear it”. Of the various ways of de-
veloping cooperation of the state and other
social agencies in aid of the practitioner, with-
out eliminating him from this field, I have
written elsewhere, and have there recorded
my belief that such a combination of interests,
with preservation of the inestimable advan-
tages of individualism in medicine, can be
brought about. I should not, therefore, im-
pose on your good nature and time in mere
repetition, but should rather proceed to point
out as clearly as I can how you and I, and
all others who deal with syphilis, can assist in
achieving the alpha and omega of its public
health control, and ultimate extinction — the
prevention of its transmission from person to
person. Once given ideal accomplishment of
this aim, as Parran has pointed out, and the
disease should, in theory at least, disappear
within the life of a single generation. Even
though no such ideal consummation be reach-
ed at once, your effort and my effort toward
this end will assuredly bring nearer that Uto-
pian day.
I propose first to present to you certain
biologic facts about syphilis, which condition
our control of it as an infection. I do this
without apology, because I know you agree
with me that insight into first principles is the
first essential to inspired attack on a problem.
I shall next consider the control of transmis-
sion through the older, and always hopeful if
not often helpful, method of the patient’s co-
operation ; then its control by treatment, which
is the distinctive and immeasurably more sig-
nificant contribution of modern knowledge to
the problem ; and to certain special aspects of
the general thesis, including the technic of con-
trolling infectiousness in early syphilis; in
syphilis involving the problem of mar-
riage; in pregnancy; in industrial, social
hygiene and public health fields ; and finally,
that the problem may come home to you di-
rectly among physicians, nurses and dentists.
Fundamental biologic considerations ; the
life cvcle of the Spirocheta pallida. There is a
certain amount of clinical evidence that the
spiral form of the organism of syphilis, with
which we are all familiar, is not the only form
taken by the virus of syphilis; and now that
experimental study is beginning to lend tangi-
bility to the matter one can be pardoned for
introducing this phase of the subject with a
somewhat speculative turn. Paternal transmis-
sion of syphilis, difficult to imagine if the or-
ganism be conceived as riding a spermatozoon
to its destination in the ovum, to produce an
infected child from an uninfected mother,
could easily be explained if there were a rest
form of ultramicroscopic or granular type. It
is well established that the semen of the syph-
ilitic male is infectious though spirochetes
have rarely been seen in it. So, too, is the
macerated and ground tissue of the lymph-
node of the rabbit though no spirochetes can
be found with the darkfield examination.
Here, then, is the possibility of an unseen
enemy in the problem of control of the dis-
ease by prevention of infectiousness. Levaditi
and his co-workers, and of late Warthin, have
lent an unexpected seriousness to the much
ridiculed attempts of MacDonough and others
to describe a life cycle for the organism of
syphilis. While we need not expect a “Leuko-
cytozoon syphilidis”, we must be prepared to
find that syphilis may achieve an unexpected
and perhaps therapeutically inaccessible latency
through the discovery of a rest form which is
not recognizable by clinical laboratory meth-
ods, and hence difficult to test for, and per-
haps to destroy by spirillicidal agents. Such
considerations may seriously affect many of
the generalizations about to be set forth in
regard to syphilis in marriage especially.
Viability of the Spirocheta pallida. The or-
ganism of syphilis is an anaerobe, requiring,
furthermore, the presence of tissue for cul-
tural growth, and of moisture and protein so-
lutions for survival. These facts make clear
important rules governing the infectious
transmission of the disease. The organism
does not survive on dry surfaces, whether of
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
393
the body or elsewhere. Hence, closed lesions,
such as the macular and papular secondary
syphilid on the free skin, exposed to air and
dry, are not infectious, though just beneath
the epidermis the organisms are abundant.
The doorknob, the dry clothing, the room
occupied by such patients, the dust, are en-
tirely harmless. On the other hand, let the
epidermis be rubbed or macerated from the
surface of a macular or papular lesion, and in
the presence of exudate and the relative ab-
sence of air, a dangerously infectious lesion
results. These conditions are met in the
orifices and folds of the body, and in dis-
charges or secretions emanating from them.
Hence the extreme danger attaching to con-
tact with the mouth and throat, the anal and
genital regions, the axillary, inguinal and sub-
mammary folds of the patient with early
syphilis. Dressings moist with such secre-
tions, since they protect the organism from
air in the presence of a protein medium, and
instruments, including those of physician, den-
tist, and nurse, which are used in such sites,
are dangerous. Contacts with such regions
(and note that these are, like kissing and sex-
ual intercourse, the intimate and emotionally
controlled rather than the reasoned contacts
of life) are the prime sources of transmission
of the disease. While these facts are being
emphasized, let it be noted that the older con-
ception of an abrasion of the receiving surface
as essential to infection, which has given rise
to much false sense of security, is an error
abundantly disproved by experimental evi-
dence in even a relatively resistant animal like
the rabbit. Opinion now leans as far in the
other direction, in the suggestion of Kolle,
that there is a definite type of human carrier,
who, like the mouse, has acquired his infec-
tion without abrasion or reaction, and who re-
distributes it perhaps without open or obvious
lesions. It is possible to acquire syphilis with-
out an abrasion, and without a chancre, and to
become a focus of distribution without being-
aware that one has the disease. This is the
role apparently played by an unknown pro-
portion of those patients, discovered by routine
application of the serologic tests to general
medical examination and diagnosis, who truth-
fully deny infection and have never realized
until late symptoms appeared that they had
the disease.
The action of disinfectants upon the or-
ganism is significant. While the Spirocheta
pallida is easily destroyed by weak disin-
fectants. it is only too frequently protected by
the protein tissue constituents of solutions by
which it is carried or surrounded. Failure to
thoroughly wash before applying prophylaxis
may, therefore, be fatal to effectiveness.
There is a tragic absurdity in the spectacle of
of an assistant putting tincture of iodin on a
deep needle puncture obtained in operation
on an active syphilitic, or of a nurse rub-
bing in calomel after a similar accident in
drawing infectious Wassermann blood. The
needle prick is the chief source of direct blood
stream inoculation without chancre, unless
nowadays negligent blood transfusions may
outrank it. There is an additional disconcert-
ing thought connected with chemical prophy-
laxis. In the recent International Congress at
Copenhagen, Zurhelle showed that application
of prophylactic ointments may simply act to
prolong the incubation period rather than to
prevent infection of the individual with syph-
ilis. It is a matter for serious question,
whether prophylaxis apparently successful,
because no lesion appears, may not have simply
cloaked rather than actually prevented infec-
tion. In practical work then, soap, water, and
boiling, stand first, as with other disinfection,
and false security from questionable precau-
tion is more often a pitfall than anything else.
As I shall say over and over, a sense of se-
curity and a low index of suspicion are the
chief sources of infection with syphilis.
Localization factors. The association of
syphilis with genital contacts is not purely
fortuitous. The recent observations of Raiziss,
to the effect that Spirocheta pallida, if in-
troduced into the cerebral ventricle of the
rabbit, does not give rise to a neurosyphilis
as such, but results after a time in the appear-
ance of a testicular chancre, suggest that the
genital structures are real centers of elective
localization for the organism. Similarly, from
our own recent study of relapse phenomena,
it appears that recurrent infectious lesions
have a pronounced tendency to localize on the
genitalia, 68% appearing there or in the
394
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
mouth, and 75% of the genital recurrent
lesions being on the penis and vulva, ideally
situated for spread of the disease. The tes-
ticle, too, is notable among the elective sites
for localization of the organism. The ten-
dency to perivascular localization, so im-
portant to the future of the victim of syph-
ilis, is the result of the fact that blood carries
the organism especially during the early weeks
of the disease, but also during its course in
later years. Fruhwald showed a decade and
a half ago that the blood of a seronegative
prostitute could be infectious; and the recur-
rence of spirochetal showers in the blood
stream is the best available explanation of
the fact that a syphilitic woman may give
birth to a syphilitic infant between 2 preg-
nancies resulting in healthy offspring. Con-
trol of the hematogenous distribution of the
organism within the body is then an item in
preventing prenatal transmission of the dis-
ease to children.
Perhaps the most important of all the bio-
logic influences affecting the transmission of
syphilis, and one of the least appreciated, is
time. The acutely infectious period of syph-
ilis covers the first 5 years of the disease. In
fact, infectious recurrences are largely over
by the end of the second year, 93% appear-
ing within this period. On the other hand,
time can never guarantee the non-infectious-
ness of a person with syphilis, for there are
authentic reports of infectious mucosal lesions
appearing as late as 24 years after onset of
the disease. It is true, none the less, that
sparring for time is important in preventing
the spread of syphilis, whether in permission
to marry or otherwise. Every month and
every year that can be allowed to elapse be-
tween the onset of a syphilitic infection and
a possible transmitting contact, decreases the
risk of infection. The chancre, the moist
lesions of the secondary period, and the re-
lapses on the mucocutaneous surfaces and the
genitalia, are the chief sources of dissemina-
tion of the disease.
The relapse factor. We all recognize readily
enough, perhaps, the primary infectiousness
of sy^philis during chancre and secondary
periods. Most patients can be made to ap-
preciate the danger they are to the community
in these stages. But relapse as a source of
the disease has never been fully appreciated
by the practitioner though the syphilologist has
harped upon it since the days of Ricord. In-
fectious relapse is relatively unobtrusive, pain-
less, and very easily overlooked. It occurs in
sites invisible to the patient, and rarely ex-
amined by the physician. While numerically
1/5 as important as the chancre in transmis-
sion of the disease, the recurrent lesion is al-
most equally important as a source of infec-
tion because of the considerations just men-
tioned. Here, again, a false sense of security,
engendered by a little treatment, and a low
index of suspicion, spread syphilis.
The serologic factor. The response of the
Wassermann and precipitation tests to treat-
ment for syphilis has led us to one exceed-
ingly dangerous and unwarranted generaliza-
tion— that cure and non-infectiousness pro-
gress hand in hand. The facts regarding the
use of the Wassermann tests as a guide to
infectiousness are these: Infectious lesions
may appear immediately following the obtain-
ing of a negative blood test on patients as
late, in my own experience, as 6 years after
infection. They may appear while the blood
Wassermann reaction is negative, and the
Spirocheta pallida may even be demonstrated
from them by darkfield, as in a case I pre-
sented to an army class during the war. I
have known a physician to authorize inter-
course between a Wassermann negative hus-
band and an uninfected wife, without the use
of a condom, and 3 months later the wife was
brought to me with early secondaries. The
syphilitic chancre is never so infective, and it
literally swarms with Spirocheta pallida, as
at the precise period in the disease when the
actively and acutely syphilitic patient is Was-
sermann negative. The sharpening of the sen-
sitivity of serologic tests has not helped the sit-
uation because, although as high as 96.5% of
clinically recognized relapses give positive
Wassermanns, these positive tests are obtained
in the presence of the full blown lesion, after
the damage is in all probability done, and not
as anticipatory warning that the patient is about
to become infectious. There is, therefore,
only one course for the physician to pursue in
practice. Dismiss the Wassermann or any
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
395
other serologic test from the mind as evidence
of the infectiousness or non-inf ectiousness of
a patient with syphilis. Tt has literally nothing
to do with the question, and only ultimate dis-
aster can follow any attempt to use it as proof
of the presence or absence of the infectious
state.
The syphilitic carrier. All sorts of inter-
esting problems surround the syphilitic car-
rier, and I have already alluded to them in
quoting Kobe’s views on the prophylaxis
problem in relation to the production of
asymptomatic carriers. An extremely serious
phase of the carrier problem concerns the
production of chronic infectious relapsers by
insufficient modern treatment. Morton Smith
some years ago called attention to the dis-
appearance of early lesions of the conven-
tional primary and secondary types under the
regime of a few doses of arsphenamin. He
might well have stressed their replacement by
the arsphenamin recidivist, the product of an
era of inadequate treatment. In the old days,
the patient, under pills, relapsed and relapsed
until the cumulative immunity reaction plus
the slow effect of the drug brought the process
to a symptomless latency. Conditions were
as bad as they could be with respect to trans-
mission. The immeasurably greater potential
benefits of the new era, however, have not
been realized, because not only does the
amount of arsenical generally used by the
practitioner in a given case fall far short of
what is needed for cure, but his interference
with, and defeating of the immunity reaction
by insufficient treatment converts the patient
the more easily into a chronic recidivist. This
generalization applies especially to the group
of seronegative primary cases in which treat-
ment is begun in the chancre stage before
secondaries appear, for it is now definitely
apparent that development of full-fledged
secondary lesions tends to protect the patient
from subsequent relapse. The patient whose
early symptoms have been abolished by a few
doses of neo-arsphenamin, enters on an in-
determinate period of danger to his commun-
ity, represented by the general statement that
approximately 10 to 13 times as many patients
relapse after 8 injections of an arsphenamin,
as after 28 injections. I shall apply this ob-
servation again, later, to the principles of
treatment for the prevention of early relapse.
Meanwhile, let us not forget the infectious
relapse.
Control of infectiousness through coopera-
tion of the patient. In the days of mercury
and iodide as the sole agents for the treat-
ment of syphilis, the disease, as I have said,
ran its course through a series of infectious
relapses in which the control of transmission
was largely in the hands of chance and the
patient. The results of this state of affairs
are before you in the wide spread prevalence
of syphilis today. No system of control which
depends on chance and the patient can hope
to accomplish much. Real self-denial on the
part of the patient with syphilis is rarely to
be obtained, not because he is syphilitic but
because he is human. He is the victim of a
disease which is prolonged, insidious and in-
conspicuous in its most dangerously transmis-
sible phases. His cooperation must be im-
plicit, blind, irksome, and protracted. Yet, in
the face of such considerations, plus some
knowledge of human nature, we still continue
to lay down rules for his guidance without
regard to the realities of the situation.
In order that you shall not judge me de-
ficient in respect for the proprieties sanctified
by tradition, I set before you here a tabular
presentation, both of the facts of infectious-
ness and the rules to be observed by the pa-
tient for their control. God bless and prosper
your efforts to secure their observance. I still
preserve enough faith in mankind to make
every patient who comes to me with an early
infection read them through.
Summary of the Facts of Infectiousness
( 1 ) The more recent the infection, the more
dangerous.
(2) The blood Wassermann is not a guide
to infectiousness or non-infectiousness. It
may be negative with infectious lesions pres-
ent and positive in non-infectious cases.
(3) The most infectious lesions are:
chancre, mucous patch, condyloma, moist
papule (flexures).
(4) The places to look for infectious re-
current lesions in inspection are: lip (outer
396
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
and inner surface), angles of mouth, faucial
pillars and tonsils, sides and bottom of
tongue, axilla, nipples, inguinal folds, labia,
penis, scrotum, anus (piles).
(5) All open or eroded lesions in early
syphilis are dangerous.
(6) Infection is also transmitted by semen
and by benign non-syphilitic lesions (herpes)
in patients with syphilis.
(7) Syphilis is transmitted mainly by in-
timate contact of moist surfaces; i.e., by kiss-
ing or sexual intercourse.
(8) Moist articles and discharge-bearing
dressings and articles of common use can also
carry infection.
(9) Thorough washing in hot water and
soap disinfects contaminated objects. The ad-
ditional precaution of boiling dishes, utensils,
and such articles as douche nozzles, instru-
ments, etc., in soda solution may be used.
(10) Dry objects, and dry (not crusted)
lesions are non-infectious.
(11) Pyogenic infection reduces the in-
fectiousness of the local lesion.
(12) Trauma by an infected object
(knuckle striking teeth, needle prick) makes
infection almost certain ; it may be hema-
togenous and without chancre.
(13) Transfusion is a means of trans-
mitting syphilis. A single negative blood
Wassermann test in the donor does not pro-
tect.
(14) There is a distinct infectious relapsing
type of syphilis that must be watched for.
To such a patient, no assurances can be made.
(15) Local irritation favors infectious re-
currence; dirt, sweat, discharges, friction (in-
tercourse) tobacco (smoked or chewed).
(16) Time diminishes the infectiousness of
syphilis. After 5 years few cases are infec-
tious ; desultory, non-curative treatment, with
relapses, may prolong infectiousness many
months or years. No treatment can guarantee
the non-infectiousness of syphilis indefinitely.
(17) Secondary relapses have been seen
with general paresis after 20 years. Inade-
quate treatment favors infectious relapse.
( 18) Late syphilids are not infectious even
though open lesions are present. Do not con-
fuse with recurrences.
(19) Mercury does not control infectious-
ness.
(20) Bismuth, while more effective in this
respect than mercury, is probably less so than
arsphenamin.
(21) Arsphenamin controls infectiousness,
probably as long as 1 month from the last
dose.
Summary of Personal Hygiene Instruc-
tions for the Syphilitic Patient
(1) Do to others in this matter as you
would wish them to do to you if you were
well and they sick.
(2) Don’t kiss. Change your disposition if
you have been effusive.
(3) Sleep alone.
(4) Trust wife or husband with the facts.
(5) Have your own towels and dishes at
home. When away, eat where you know they
scald the dishes.
(6) Never use another person’s shaving
tools, his cup or dipper, his spoon or other
eating tool, his pipe or cigarette holder, his
toilet articles, and never let him use yours.
(7) Consider every open sore infectious
until you have seen your doctor. Burn the
dressings.
(8) Watch for “patches”, cold sores,
cankers, pimples, chafes and piles, and see
your doctor if they appear. Consider yourself
infectious.
(9) Get your doctor's instructions rela-
tive to sexual matters, and follow them.
(10) Don’t smoke, if you are within 5
years of the beginning of your infection.
(11) Don’t worry. Keep free of mental
strain as much as you can.
(12) Sleep 8 hours a night.
(13) Avoid over-work, but keep reason-
ably busy.
(14) Gain weight unless your doctor says
not.
(15) Exercise as usual in the open air,
unless otherwise instructed.
(16) Avoid chilling and getting wet.
(17) Report all colds, coughs, sore throats,
and other infections to your doctor while you
are under treatment.
(18) Avoid injuries. They may start
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
397
trouble. Be especially careful to avoid sprain-
ed joints and blows on bone.
(19) No alcoholics.
(20) Realize that your chances are good
for recovery, and make the most of them.
There is one way in which the physician
can further the value of the patient’s cooper-
ative effort in the prevention of infection.
This is through thorough examination and re-
examination at every possible opportunity
during the early years of the disease, to de-
tect the presence of a relapsing tendency, and
of actual relapse lesions as such. In spite of
what I have said about the unreliability of
the Wassermann test as evidence of infec-
tiousness, it does have a certain significance
in the early months of treatment. Moore and
Kemp have shown, that a relapsing tendency
is indicated by the too early decline of the
Wassermann to negative under treatment. It
is also well known that recurrence of a posi-
tive after a series of negatives in an early
case is a warning of the existence or pros-
pect of relapse in some group of structures.
It is, moreover, known that seronegative
primary syphilis which becomes positive with-
in a few days after the first injection of an
arsphenamin, behaves much as does seroposi-
tive primary syphilis with respect to an in-
creased tendency to relapse when treatment is
stopped. Finally, there exists in man as in
animals, a definite relapsing type, which does
not accumulate resistance to the disease ex-
cept at the expense of repeated cutaneous re-
actions, most of them in potentially infec-
tious form, during the first 5 years or so of
the disease. These are the patients with de-
layed secondary eruptions especially. To
utilize these considerations in practice calls
for frequent repetitions of the serologic tests
within the first weeks or months of the dis-
ease (Moore and Kemp performed them once
a week) ; and systematic search for the re-
currence of infectious lesions about the mouth,
throat and genitalia, especially after treatment
is suspended. It is impossible to over-empha-
size the necessity for thoroughness in such re-
examination of treated patients. No swivel-
chair examination and “Oh you look all right”
technic will do the work. It is necessary to
burrow into the corners with light and tongue
blade ; to evert the prepuce, paw over and in-
spect the scrotum, especially the posterior sur-
face, and see the anal opening; to attentively
study the flattened palms and soles. I know
from experience how irksome and time-con-
suming this is, but you will be rewarded by
some startling discoveries among your sup-
posedly cured patients. Look especially for
mucous erosions, supposed fissures with grey-
ish pellicles, “warts”, supposed hemorrhoids,
“herpetic” lesions on the penis, and the ringed
recurrent lesion of the scrotum.
Control of infectiousness by treatment. An
understanding of a few fundamental prin-
ciples here aids in the application of rules and
standards to the individual case. Contrast for
the moment the situation of public health con-
trol with respect to syphilis and tuberculosis.
In the latter disease, education, isolation, and
hygienic attack are still our chief weapons. In
syphilis, while these methods have their worth,
they are of minor import because they cannot
stem the countercurrent of the basic urge
which underlies the prevalence of the venereal
diseases. Without a new weapon, we would
be as we are with gonorrhea, at a standstill.
Our new weapon is chemotherapy, as yet un-
known in tuberculosis, but already far advanc-
ed with respect to syphilis. It is not too much
to say that it is arsphenamin, and arsphen-
amin alone, that makes hopeful the ultimate
extinction of the disease. It is essential, there-
fore, to understand the action and peculiari-
ties of the arsphenamins if we wish to do our
utmost to control the disease.
Action of the antisyphilitic drugs. Action of
the arsphenamins is clarified by a comparison
with that of mercury and bismuth. An
arsphenamin acts upon the spirochete through
the medium of its oxidation products, and de-
stroys it outright with comparatively little ef-
fect on the tissues. Mercury, on the other
hand, in the body, has little effect on the
spirochete, but acts rather by stimulating tis-
sue resistance to the organism, and perhaps
by stimulating the cell to make its own slow
and only partially effective resistance to the
disease. Bismuth is intermediate between these
types of action, a better spirillicide than mer-
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
cury, but a much poorer one than arsphena-
niin. The action of an arsphenamin upon in-
fectiousness may he summarized by saying
that an effective arsphenamin in adequate
dosage destroys every surface organism, and
hence renders the patient non-infectious with-
in 24 hours. The duration of this sterilization
is short, and is made permanent only by repe-
tition of the doses at intervals not greater
than a week, for a long series. The action of
mercury with respect to infectiousness is
summarized by saying that condylomas swarm-
ing with spirochetes may develop around the
anus, right in the middle of a course of the
most popular insoluble mercurial salt (mer-
cury salicylate). Bismuth will sterilize, but
its action is 3 to 8 times as slow as that of an
arsphenamin.
Arsphenamins vary in their spirochete-
destroying power. Neo-arsphenamin. though
so popular, is notably uncertain in this regard,
and Dale and White were able to show that
a good deal of what was labelled and sold as
neo-arsphenamin in Great Britain during the
war, was powerless to destroy the Spirocheta
pallida. Voegtlin confirmed some of these
observations for neo-arsphenamin made and
used in this country. It is important to real-
ize that the spirochete-destroying power of an
arsphenamin is not due to arsenic as such.
For that reason, other arsenicals, especially
the pentavalent drugs such as tryparsamide,
and the cacodylates, have no value in tracing
infectious syphilis, for they are feebly or not
at all spirillicidal. It is the valence of
the arsenic-linkage to the dye base that
counts.
The complete dependence of the prevention
of infectiousness, not to say even the so-called
cure of the disease, upon the arsphenamins is
perfectly illustrated by a number of recent
clinical observations. Moore and Kemp found
a definite decline in the frequency of recur-
rent secondary syphilis proportional to the
number of arsphenamin courses received by
their patients. Of 196 patients receiving from
1 to 8 injections of an arsphenamin, 80% had
potentially infectious recurrences; of 89 re-
ceiving 6 to 12 injections, 10%, or only half
as many, relapsed; of 46 receiving 13 to 20
injections, 10%, and of 71 receiving 21 to 40
injections, only 5.6% relapsed into potential
infectiousness. Besancon, Schoch and I found
in my own clinic that 85% of our patients
who relapse with the appearance of infectious
lesions have had less than 12 arsphenamin
and 10 heavy metal injections, a figure which
exactly confirms the 88% found by Moore
and Kemp. The study presented before the
International Congress of Dermatology and
Syphilology this summer showed with clear-
ness and exactitude based on large numbers
of cases collected from 5 cooperating Ameri-
can clinics, that the critical point for a large
proportion of patients with reference to the
prevention of potentially infectious relapse,
lies between the fifth and the ninth injection
of “606”. Even with identical amounts of
heavy metal in both groups, those who re-
ceived only 1 to 5 injections of arsphenamin
relapsed 5 times as often as those who re-
ceived 5 to 9 injections.
Modern treatment, then, depends for the
prevention of infectiousness, on the arsphen-
amins, and not on either mercury or bismuth,
essential though these elements are in the
successful outcome and “cure” of the indi-
vidual. The patient in the first 2 or 3 years
of a syphilitic infection who receives from
his physician less than 20 arsphenamin in-
jections, remains a vastly greater danger to
his contacts and the public health, than does
the patient who receives more than 20 injec-
tions.
My time allotment must have consideration
— so that I know you will pardon the didac-
ticism of a succession of short summaries
setting forth application of the foregoing
principles to various special phases of syph-
ilis, to which we shall now proceed.
Control of infectiousness in early syphilis
( first 3 years). This is “Today’s World Prob-
lem in Disease Prevention”. Let me stress to
you the vital importance of 2 factors, time
and arsphenamin ; time , because every hour
gained in putting an early infection under
treatment nips future contacts, and increases
the proportion of radical cures ; arsphenamin,
because, as I have shown you, it is the only
quick destroyer of the organisms, and the ab-
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
399
solute leader in the field of infection control.
On the question of time, I might harangue
you on the darkfield, as all of us have done ;
and leave you without the knowledge or equip-
ment to use it. I recognize the individual im-
practibilities of the darkfield, and I therefore
urge you not to buy the instrument and use it,
but to require of your state laboratory that it
develop a darkfield service comparable to its
present Wassermann service, and supply you
with the pipettes and mailing cases to secure
for your patients with suspected chancres
darkfield examination of the chancre serum
within the first few days of the life of the
lesion, while the blood is still negative to
Wassermann and Kahn. If your state will
not provide the service, get it from the hos-
pital or pathologist in your neighborhood.
Develop a local darkfield man who knows his
spirochete when he sees him, and try for cure
in the seronegative phase. Refuse to listen,
first of all, to those of the “Old Guard” who
advise you to wait for secondaries to appear,
in order to “give the patient a good reaction”.
There is absolutely incontestable evidence that
though this may affect somewhat the tendency
to recurrence, it reduces the prospect of cure
for the individual 25 to 40%. More than that,
withholding arsphenamin maintains for days
and weeks a focus of dissemination of the
disease in the community, not subject to
quarantine, and unquarantinable even if regu-
lations existed, that spreads syphilis broad-
cast as of old. Throw the detail man out of
your office who advises you to try his firm’s
intravenous preparation of bismuth alone on
an early case — or any other preparation but
an arsphenamin compound. The French have
tried bismuth this way, to their sorrow. Even
the contrast between an arsphenamin and an
arsphenamin-bismuth compound is illuminat-
ing in this particular, for an arsphenamin
alone in adequate dose is 3 or 4 times as fast
a sterilizer of active lesions, as is the ars-
phenamin-bismuth compound — bismarsen ;
though properly used, bismarsen is apparently
the superior from the curative standpoint. It
is possible without in any wise sacrificing the
interests of your individual patient to pre-
serve fully and further the public health con-
cern in the early effective use of an arsphen-
amin.
Of the subsidiary principles involved in the
control of infectiousness in early syphilis, I
would offer these. Allow no rest periods in
the first 18 months, for these lead to relapse.
Use a heavy metal, preferably now-a-days bis-
muth, side by side with and in the intervals
between arsphenamin courses. Be moderate
in dosage, but effective, for less than 0.3 gm.
of an arshpenamin is of doubtful utility, and
more than 0.5 gm. of “606” or 0.6 gm. of
“914” may destroy tolerance and cut treat-
ment short. Mass the patient’s treatment
early, giving the injections closer together at
the start, and getting all the treatment you
can into the patient within the first 3 or 4
months. Then keep on, and try in every early
case to reach 36 to 40 injections of an ars-
phenamin in courses of 12, 10 or 8 injections,
plus the accompanying bismuth. Never, no
matter what the stage or circumstances of the
case at the start, give abortive cures, a single
course of 8 injections or less, and put the pa-
tient on pills or any other form of treatment
than a continuance of his arsphenamin. Abor-
tive cure has disappeared from the practice
even of Germany, which originated it. Treat
every case to a maximum, determined, not by
your personal experience with a few patients,
or your detail man’s experience with none, but
by that of the syphilis clinics of the world as
presented in the literature and through your
state and national venereal disease services.
Control of infectiousness in late syphilis.
Here the time factor is paramount. Lose your
dread of the gumma and the tabetic patient
if you have any, for transmission of the dis-
ease does not lie at their door. I believe it
was Hoffman who reported the famous ex-
ample of a man with gumma of the penis,
who, though by no means abstemious in un-
protected intercourse, did not transmit the
disease to his uninfected partner. Latency in
marriage, is, of course, a special problem, to
be presently mentioned, but, in general, one
need not fear the infectiousness of late syph-
ilis nor make life unduly hard even for pros-
titutes who have had the infection for a dec-
ade or more.
Control of infectiousness in sexual relations
400
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1031
and pregnancy. You will notice, of course,
that I have not said “marriage and preg-
nancy’’ ; for I would wish you in considering
this matter to be realistically rather than mor-
alistically minded. Marriage is only a part
of the problem, as one well realizes when a
seemingly intelligent young man replies to his
doctor's warnings by saying, “Why of course
I would not stay -with any nice girl, Doctor,
while I have this thing’’. Whether for better
or for worse, the niceties have faded out of
the modern situation with decline of the
double standard, and the instructions to the
patient and the course to be pursued in refer-
ence to possible sexual contacts must be the
same for the married and the unmarried.
Therefore, I suggest that you lay before all
patients, in the first interview after diagnosis
is made and the first treatment given, the
facts I have recounted to you, regarding
time-treatment relations in the transmission
of the disease. I suggest you set 40 ars-
phenamin injections, rather than 5 years, as
a probable landmark in the resumption of
sexual activity. Then, if you live in a state
or community where enlightenment is pos-
sible, remember that infectious recurrence in-
volves especially the penis, the vulva, and the
mouth parts, and that the semen may be in-
fectious. Keep them apart by impervious
protection rather than chemically. Though I
speak in terms of almost urologic barbarity, I
would not belittle the influence and worth of
ethical pressure, and would spar for time be-
tween infection and my patient’s resumption of
sexual activity by every device known to the
temple, the court and the sawdust trail. I fear
to seem facetious or cynical, for these issues
are critical, and a religious or moral appeal
that holds even an occasional man to arsphena-
min and keeps him from women, has public
health worth. Remember again not to base
decisions as to infectiousness on negative
serologic tests, lest you wreck some innocent
woman or child by premature permission to a
husband. And, once you have in your best
judgment authorized sexual activity, keep
constant check upon it in the early years,
limiting it to the times when the patient is
under arsphenamin control, if possible.
The problem of preparation of the intelli-
gently cooperative man or woman for the con-
ception or bearing of a child is still on a
theoretic basis, for so few patients can be
kept under the necessary control for the pur-
pose. In theory one should prepare both the
syphilitic man and woman for the conception
of a child with an arsphenamin and bismuth
course. More frequently we are called upon
to deal with the situation and prevent infec-
tion of the child only after conception has oc-
curred. On this matter there can no longer
be 2 opinions. I cite you simply for concrete-
ness the notable statistics of Boas and Gam-
meltoft (Nabarro, Brit. Jour. Vener. Dis.
1928, 4:107). In a total of 201 cases of syphi-
litic mothers receiving no treatment for the
disease, 96.5% of the children were syphi-
litic, and 3.5% healthy. Of 87 syphilitic
mothers receiving mercury before pregnancy
but none during, 90% of children were syphi-
litic and 10% healthy. Of 15 mothers receiv-
ing arsphenamin before pregnancy, but none
during, 80% of children were syphilitic and
20% healthy. Of 111 mothers receiving
mercury only during pregnancy, 72% of chil-
dren were syphilitic and 28% normal. Of 26
mothers receiving arsphenamin before and
mercury during pregnancy, 27% of children
were syphilitic and 73% normal ; while of 105
mothers receiving arsphenamin during or both
before and during pregnancy, from 15 to
20% of children were syphilitic, and from 80
to 85% normal. It is unnecessary to point the
moral of these figures. Translated into prac-
tical terms, every pregnant woman, regardless
of age, social status or other circumstances,
should have a serologic test for syphilis as
soon as she is first seen by her obstetric at-
tendant, and this test should be repeated by
the seventh month. Every mother who has or
has had syphilis, regardless of the age of her
infection, of her serologic findings, whether
positive or negative, and almost of her general
state, can and should have some arsphenamin,
preferably both before and during, but .at
least during, her pregnancy. The prescription
may vary in individual cases, for a syphilitic
heart or liver, for example, modifies the rule;
but in general, the arsphenamin should be be-
gun early, given through the larger part of
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
401
the pregnancy, and be combined with bismuth
at least part of the time. The dosage can be
moderate, but should not be picayune, and the
follow-up of mother and child must be com-
plete and protracted. An enormous harvest
of prevented infection with syphilis awaits
the adoption of these rules by the profession
at large.
Control of infectiousness in industrial re-
lations. My time and your patience are hardly
lengthening, so that I devote only a word to
this interesting subject. The crux of the
syphilis problem in industry is recognition of
the infected person. Perhaps I might place
ahead of this the problem of getting the issue
before the czar-like official autocracies that
too often bar the way. The principles in-
volved are these, as I learned them in my
study of railroad men. Syphilis is overwhelm-
ingly acquired in youth. It is infectious in its
early years, and coincidently it is apt to be
serologically positive during this period. The
appropriate mass measure, aside from detailed
periodic physical examination, is the taking of
the blood Wassermann test on all persons be-
tween the ages of 17 and 31, on entering em-
ploy, and at such intervals thereafter as may
be practicable within the age period named.
Understand that this Wassermann is taken
not to detect infectiousness but to identify the
presence of syphilis. Further medical exam-
ination is then essential to determine the status
of the detected case, which may, of course,
not be infectious at all, even though serologi-
cally positive.
As a matter of fact, with disappearance of
the common drinking cup (if it has disappear-
ed), the transmission of syphilis in industrial
relations as such, is probably of small moment.
When both sexes work in contact, it is more
important to attack the social hygiene problem
than the epidemiologic one, through the instru-
mentality of matrons, effective shop discipline,
and education. Even in food handlers, and
cosmetic workers, the risk of transmission of
syphilis may be exaggerated, though it is true
that one sometimes shivers when one watches
the technic of barbers, dining-room, kitchen,
and soda fountain help, from behind the
Scenes. Periodic serologic testing of such
persons is probably desirable for detection
purposes. The most tragic aspect of the mat-
ter is the least known — the children infected
by irresponsible and immoral servants in the
home. I have seen everything from tabes in
the house-mother of a great girls’ school
dormitory, to a chancre on the penis of a 2-
year old baby, traced to the activities of the
crooked and infected nurse. Here at least is
a field that merits genuine effort at study and
control.
Social hygiene and public health aspects.
The reservoir of syphilis, up to the War, was
prostitution, organized and unorganized. It
is impossible to quote the vast mass of figures
from every source demonstrative of this fact,
but in the study of prenatal syphilis and of
the infected father and mother which I made
preparatory to the chapter of my text on this
aspect of the disease, the realization was most
clearly brought home to me. Of the fathers
of my little syphilitic patients, 90% had ac-
quired the disease extramari tally. Just what
role the so-called emancipation of women is
likely to play in the dissemination of syphilis,
is as yet largely material for speculation. I
question if the role will be a large one — the
worldly-wise maiden is beginning to under-
stand the protective virtues of caoutchouc too
well to take unnecessary chances, if my im-
pressions from the venereal confessional are
any guide. At the same time, Jeanselme and
Burnier seem to feel that increasing prostitu-
tion is a significant force in the wrong direc-
tion. Two or 3 things do seem to stand out,
that deserve mention. The younger a prosti-
tute, or a free lance, the more dangerous, for
obvious reasons, and hence the more in need
of control. This word raises at once the
question as to whether there can be such a
thing as control. Some very interesting ex-
periments have been tried recently in this di-
rection, among them Kolle’s effort to keep
prostitutes non-inf ectious by the injection of
what he called “bismuth plugs” intramuscu-
larly, which he hoped would prevent the de-
velopment of infectious lesions. Nothing not-
able has been published thus far to my knowl-
edge on the matter. I may tell you that my
lifetime’s experience with syphilis, such as it
402
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
is, has made me an abolitionist. No one who
knows the disease seriously expects to control
or influence its incidence by the provision of
segregated districts and inspected girls. Public
health control of venereal disease as it con-
cerns the infection focus centers around the
tracing of the source of each and every early
infection identified, and the immediate steril-
ization and supervision of that infectious
source by every available means, but most of
all by making treatment not so much forced as
attractive and easy. Every practicing doctor can
contribute to this end by trying to bring in the
source from which his patients are infected
and by demanding of the state that it inter-
fere here, instead of in the treatment of tabes
and paresis, the mere non-infectious end-re-
sults. A state social service could do won-
ders in backing the doctor by bringing in for
treatment the foci that spread the disease
among his patients. The report and the quar-
antine, while orthodox weapons, have helped
me far less than the 2 or 3 socially minded
and intelligent women that used to trace
sources for Irvine in Minnesota during the
war. The entire policy of a great nation,
England, in dealing with the venereal dis-
ease, is founded on cooperation and education
rather than compulsion — not without some
protest, however.
Let us do what we can, too, to spoil the
business of the druggist who prescribes and
dispenses to venereal patients. He ruins the
early detection of the disease too often. And
let us not expect too much of personal chemi-
cal or packet prophylaxis. I see something of
it among men of more than average intelli-
gence, and I doubt if among the average it is
worth anything at all. A half-drunk man and
a prophylactic packet are no match for the
spirochete. Remember that it is station
prophylaxis under organizational conditions
that worked the wonders on the venereal situ-
ation in the War.
Control of infectiousness in physicians,
dentists and nurses. You remember the an-
cient saying that “curses like chickens always
come home to roost”. My closing paragraph
is the appropriate place for such a consum-
mation. No one who deals with syphilis day
in and day out can fail to realize the tragic in-
cidence and the deplorable outcomes of the
disease among those whose professions bring
them into contact with it. Several facts have
high significance here. Syphilis is the danger-
ous unexpected. It is not the svphilologist who
acquires it, even from a lifetime of potentially
dangerous contacts. It is the practicing doc-
tor, secure in ignorance, of a low index of sus-
picion, of a mistaken casualness and bravado,
and irresponsible in treatment who meets ruin
in this way. It is a legitimate demand on the
public in protection of professional attendants,
that patients submit to a routine test for
syphilis as a part of every medical examination.
Now that the precipitation tests are coming to
the requisite simplification (as witness the
presumptive Kahn and the finger-test Kline),
it is no longer necessary to remain in ignor-
ance of a patient’s condition on this important
point. One can know that one is dealing with
potentially infectious material within 20 min-
utes. where such facilities are available. No-
where will such a help be more important, if
I may digress momentarily, than in the pre-
vention of transmission of the disease by
blood transfusion, one of the most shocking
and regrettable miscarriages of modern thera-
peutics that can befall a hospital or a medical
staff.
Two additional items calculated to protect
the profession from accidental syphilis are an
adequate light in examination of patients in
the office ; and, an absolutely unbreakable
habit of inspecting orifices. If the examina-
tion of the fourchette and labia before passing
the palpating finger ; of the commissures, buc-
cal mucosa and throat before introducing
dental instruments ; of the anal and vaginal
openings before passing tubes and thermome-
ters ; were conducted with a good flash lamp,
many a finger and many a life would be spared.
Good gloves, new gloves, and condign punish-
ment for pinholed gloves handed to an ex-
aminer, would mean much. The habit of warn-
ing the patient not to cough ; the learning of
that difficult art of looking at not merely,
through or past the small things one encoun-.
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
403
ters on an orificial inspection; these would
help. Special realization of danger on the
part of those who deal with the woman’s in-
visible genital tract in diagnosis and treatment,
and those who operate upon the nose, throat
and anus, where danger is always imminent
and always unexpected, would help. And
when infection occurs, some medical knowl-
edge of the extragenital chancre — which is
not a felon, not a boil, not a sarcoma, not
“just an infection”, would help, too. Indura-
tion, indolence, and satellite adenopathy, the 3
keystones to physical diagnosis of the chancre,
could help us to an early darkfield, and early
diagnosis, and a probable cure, much oftener
than they do.
I would recommend it to you as a pro-
tective procedure, that your patients with
recognized and not recently treated syphilis
who are up for operation, receive, if no
emergency or special aspect of the disease
contraindicates, 1 or 2 injections or 0.45 gm.
neo-arsphenamin before they are operated on.
At least ask the advice of a syphilis man on
the matter. I know the risks of surgical in-
fection with syphilis are small in some as-
pects of the work ; that there are hoary-headed
masters of the surgical art who have come
through 40 years of operating untouched so
far as they know. But I have seen too many
men marred.
Writing this paper in my study, I picture
my audience as hearing with patience and
comprehension — perhaps, too, with some con-
siderate indulgence — the effort of one who
was once kindly called a crusader, to bring
this subject home to you. Being generously
disposed to strangers, and, as your records
show, genuinely concerned over this aspect of
the public health, your enlightened outlook
will accept, I know, the conclusion of the
whole matter. The responsibility for the
modern control of the infectiousness of syphi-
lis is not in the hands of the church with its
preaching, the law with its mandates, or the
laboratory with its drugs. It lies today, to be
met or ignored, with the everyday doctor.
VALUE OF BLOOD SEDIMENTATION
TEST IN GYNECOLOGY
John Huberman, M.D.,
Newark, N. J.
During the past few years a great deal has
been written on the clinical significance of the
sedimentation test, which has been on trial
for some years in this country and abroad. Its
value has been emphasized by the following
investigators : Popper and Kreindler find - the
test a valuable aid in diagnosis and prognosis.
Netschman uses it in differential diagnosis,
especially in conjunction with a complete
blood count. Frosch believes the sedimenta-
tion test more delicate than the blood count
can be. Barr and Reis, from Michael Reis
Hospital, in Chicago, and Friedlander, of
Detroit, advocate it in gynecology. Some
workers report unsatisfactory results, such as
Cherry and Schmitz, whose difficulty would
seem to be one of interpretation. The figures
obtained by them and on which they base their
condemnation of the sedimentation test are
so at variance with the rates obtained in the
various gynecologic case types by practically
all other workers in this field as to warrant
the impression that their cases were compli-
cated by undetected remote foci of infection
or were of mixed pelvic pathology. Men like
John Osborne Polak have had tests made on
every patient admitted to the gynecologic
wards of the hospital and 1000 readings have
been made from which the rates of sedimenta-
tion have been tabulated and definite deduc-
tions drawn. In gynecology a large proportion
of our operative work is elective, and we must
strive to eliminate every possible factor which
may contribute toward a prolonged convales-
cence, especially factors involving the recogni-
tion and elimination of infection.
It might be well to emphasize at once that
we are clinicians and not laboratory tech-
nicians. We are treating patients and not
simply making tests, and of course the clini-
cal course is the outstanding factor in hand-
ling our patients. We use the leukocyte count,
temperature curve and, in addition to our
404
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
clinical data, the proper interpretation of the
sedimentation test. This investigation was
undertaken by our service in order to deter-
mine whether the blood sedimentation test
offers additional information of either diag-
nostic or prognostic value. If this test adds
something to our clinical knowledge that may
help us to determine the presence of latent
infections, and when to operate and when not
to interfere, it is worth using routinely, con-
sidering its simplicity.
Let us briefly review the history of the
sedimentation test. The hastened settling of
inflammatory blood has been known to physi-
cians for centuries and was considered a par-
ticularly important clinical sign, both theoret-
ically and practically. With cessation of ,
blood letting and the advent of cellular path-
ology, it practically had become forgotten and
is now observed again independently by a
modern investigator with a new meaning and
in a new light. Many writers credit Galen as
the first to call attention to this phenomenon
under the name of “Crista Phlogistica”. John
Hunter studied the phenomenon of blood sedi-
mentation in 1791. He not only observed
that the erythrocytes settled more quickly in
their own plasma, but he was also the first to
demonstrate that the red cells of normal blood
when separated and transferred to the plasma
of inflammatory blood, settled with greater
speed, the rapidity of this process being in
direct relation to severity of the infection. In
1918 Fahrens rediscovered the phenomenon
of blood sedimentation in pregnancy and
started the present wave of investigation. It
has since been observed and studied in tuber-
culosis, cancer, various forms of joint dis-
ease, pneumonia, scarlet fever, pelvic inflam-
matory disease, syphilis, anemia, and many
other conditions.
It is not within the scope of this paper to
discuss the various theories advocated to ex-
plain the sedimentation phenomenon. It is
safe to say, however, that out of the host of
theories propounded, from auto-agglutination,
electrophysical reaction and increased fibrogen
content of blood plasma, down to the presence
of some specific ferment in the plasma, there
is not one universally acceptable explanation.
Regardless of theory, the ultimate cause ap-
parently depends upon the degree of cellular
destruction going on in the body. The sedi-
mentation reaction is generally regarded as a
measure of pathologic activity and therefore as
a symptom of a general kind. It is a fine quan-
titative measure of the change in the blood,
produced by a destructive process somewhere
in the body. It does not diagnose, nor does
it localize the infection. It does not indicate
the state of the diseased organ, hut it does re-
flect the disturbance produced in the organism
through the absorption of products of infec-
tion.
There are 2 recognized methods of sedi-
mentation reading. The first, time method, is
advocated by Linzenmeier. This method fixes
the distance and observes the time, recording
the results in minutes. The second, distance
method , employed by Westergren, where he
fixes the time and measures the distance
recording the results in millimeters. Although
most investigators in this country choose the
Linzenmeier method, we felt that the Wester-
gren method was easier for reading and more
exact for results.
The Westergren technic, as employed by
us, is as follows: To prevent blood coagula-
tion, a 2 c.c. syringe is filled with 0.4 c.c. of
3.8% sodium citrate solution. The cubital
vein is punctured and 1.6 c.c. blood is with-
drawn, which means that the syringe is filled
up to the mark of 2 c.c. and the blood sodium
citrate mixture is then put into a test tube.
By shaking, we attempt to get an equal distri-
bution of the blood cells. The blood is sucked
up into a pipette which shows a scale of 200
mm. The content between the zero mark
and mark 200 equals 1 c.c. It is not necessary
to fill the pipette immediately after the ven-
ous puncture, as the citrated blood gives the
same sedimentation after standing in the test
tube for a few hours. The pipette is fixed
then into a frame and time noted. After a
certain time the sedimentation of a red column
in the pipette is noticeable. We read usually
after 1 hour, a second time after 2 hours, and
finally after 24 hours. The most important
reading is the first hour.
The important question to be answered is
whether the sedimentation test has a practical
application. Its practicability so far as technic
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
405
is concerned is obvious for the test is simple
and requires very little laboratory equipment.
The fact that in normal individuals the sedi-
mentation is between 2 and 5 mm. in the male
and 3 and 7 mm. in the female individuals,
while sedimentation in inflammatory cases
varies according to severity of the process,
indicates the value of the test. It is a more
precise reagent than the thermometer, for ab-
sorability of infected material is promptly
recorded by variation of blood sedimentation
even when the temperature remains normal.
We cannot always claim that increased sedi-
mentation indicates an infection in that part
of the body upon which we are directing our
attention. We know, however, that there is
an infective process in some part of the body
and that we must try to . eliminate all error in
diagnosis; i.e., when the infection is not found
where it was suspected a thorough search may
locate the infection elsewhere. We read a
rapid sedimentation and operate suspecting
diseased adnexa, but instead we find normal
adnexa, and if we search further we may
find a diseased appendix or gall-bladder to
account for the rapid sedimentation.
The sedimentation test is especially valu-
able in those cases of adnexal disease where
there is a latent infection with a normal tem-
perature and normal blood count. Very often
the surgeon operates and finds such a latent
infection, which lights up and causes a stormy
convalescence, or even jeopardizes the life of
the patient. We consider an increased sedi-
mentation, above 50, a sign of latent infection
and although temperature and blood count are
normal, postpone operation until tests indi-
cate a sterile field so far as operation is con-
cerned. Whenever sedimentation is used,
operations have not been complicated by the
presence of unsuspected latent infections,
which indicates that the test succeeds in show-
ing the existence of such a condition. Because
it is known that operations increase the mor-
bidity and mortality in such infected cases, the
exclusion of a latent infection is only possible
when the sedimentation is not more than 10
to 15 mm.
Too much emphasis cannot be laid on the
importance of repeated readings. The clinical
picture and physical findings may seem to re-
main unchanged, the temperature curve and
leukocyte count may show no significant vari-
ations, while the sedimentation time is chang-
ing in direct relation to the changing condi-
tion of the patient. This holds good not only
in determining safe operability, but even more
strikingly in making a prognosis.
In the opinion of most authorities and this
is borne out in our experience, it is possible to
classify all gynecologic conditions according
to their sedimentation. Normal sedimentation
test occurs in the following: (1) Malposition
of the uterus; (2) polyps; (3) plastic opera-
tions. The readings will not exceed 10 mm.
for the first hour.
Cases of pelvic pathology whose sedimen-
tation comes nearest to normal are : ( 1 )
Simple ovarian cysts; (2) dermoid cysts;
(3) hydrosalpingitis; (4) uncomplicated
myoma. As a rule, they never exceed 15 to
20 mm. within first hour. In the presence of
an active infection, i.e. acute salpingitis, de-
generated fibroid or mixed pelvic infection,
the test shows a strikingly increased sedimen-
tation ranging from 70 to 120 for the first
hour.
An individual interpretation is required in
malignancy and ectopic pregnancy. An un-
ruptured ectopic shows only a slightly in-
creased sedimentation. A ruptured extra-
uterine pregnancy shows an increased sedi-
mentation which is in direct proportion to the
amount of bleeding and destruction of red
cells. The larger the amount of free blood
in the abdominal cavity, the higher the sedi-
mentation. Of course the safety limit of 50
mm. for the first hour does. not apply in the
case of ruptured ectopic, any more than it
would apply in cases of obstruction where
operation is vitally indicated.
Another special consideration must be given
to malignancy. Here the sedimentation read-
ing is directly proportional to the amount of
tissue destruction. An early malignancy shows
slow sedimentation which increases as the
destructive malignant process goes on.
I will now try to illustrate the value of this
test by reading a few typical case histories.
To begin with, in our group of normal or
low readings — ovarian cysts, malposition of
uterus, and plastic operations with a reading
406
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
of about 10 — we found the white and differen-
tial count in the majority of cases to conform
with the sedimentation test. Where a dis-
crepancy existed we gave preference to the
sedimentation test. We might add here that
where the sedimentation was normal or low
we did not find at operation any latent infec-
tion and the patients made an uneventful re-
covery.
The first case for illustration is a patient
in the hospital now. Mrs. S. Lien, admitted
with the diagnosis of left salpingitis, tempera-
ture 101°, pulse 120, blood count 8900, and
differential only 69%. Sedimentation taken
and found 98 for first hour and 129 second
hour, which is rather high. After a few days’
rest, first hour reading 84 and 121 second
hour. In spite of the low blood count and dif-
ferential of 69%, we are inclined to believe
that the diagnosis is acute salpingitis, with
possibility of pus. We examined this patient
vaginally 2 days later and her temperature
rose to 103°.
In this case the sedimentation tests is in
conformity with the clinical picture and tem-
perature curve, while the blood count and dif-
ferential would tend to mislead us as to the
existing pathology. In such a case we post-
pone operation until the sedimentation is be-
low 50 for the first hour although the temper-
ature and pulse may become normal. By doing
this we hope to avoid a stormy convalescence.
As a counterpart to the preceding history,
the following case might be of interest. Mrs.
J. R. was admitted with the following history :
For the past 5 weeks she had experienced a
pain in the right lower abdomen, radiating to
the right extremity and the rectum. Later,
the pressure on the rectum was the most pro-
nounced symptom, causing a constant tenes-
mus. Bimanual examination showed a palp-
able mass in the posterior cul-de-sac, which
was not fluctuating, and a tentative diagnosis
of pelvic abscess was made. Temperature
102°; pulse 100; leukocyte count of 26,250,
with 89% polys ; but the sedimentation was
normal. We did a posterior colpotomy. No
evidence of pus being found, she was treated
conservatively and went home within a week
without any pelvic pathology, and she is ap-
parently still well ; proving that the sedimenta-
tion test result was correct in spite of the clin-
ical and laboratory findings.
A third interesting case follows. Mrs. Ray
Petesky, admitted with diagnosis of “possi-
ble ectopic’’. History of vaginal bleeding, pain
in lower abdomen, difficulty of micturition and
defecation. She had missed 2 periods. Had
been previously operated on at Royal Victory
Hospital, in Montreal, for ruptured right ec-
topic. Temperature on admission 101°; pulse
100; white count of 1400 and 76% differential;
Hb., 68%. Vaginal examination showed
uterus enlarged, with an indefinite mass on
left fornix. So far, the diagnosis of ectopic
appeared to be amply justified. Sedimentation
was taken and found to be 134 for the first
and 137 for the second hour; which is maxi-
mum rapidity.
We reasoned as follows : Unruptured ec-
topic would give a low reading; not higher
than 40. Ruptured ectopic would give read-
ing in direct proportion to the amount of free
blood in the abdominal cavity. In this case
there was no evidence of internal hemorrhage
and we therefore came to the conclusion that
we were dealing with a superactive salpingitis.
The operative findings disclosed a left tubo-
ovarian abscess, and that was substantiated by
the pathologic report.
Another interesting group is that of malig-
nancy. Mrs. G. was admitted with diagnosis
of tumor of left ovary. For past few months
she had occasional sharp pains in left lower
abdomen, radiating downward. Moderate vag-
inal discharge and regular menstruation until
last month, when she menstruated twice, the
second time very profusely. Temperature
98.4°; pulse, 80; leukocytes, 13,200; polys,
76%.
On bimanual examination, large cystic mass
felt on left side. Diagnosis was made of left
ovarian cyst. The sedimentation test showed
72 for first and 96 for the second hour, and
our diagnosis was accordingly changed to
malignant cyst. Operative finding and patho-
logic report showed a papillary cyst, adeno-
carcinoma of the ovary.
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
407
The value of the sedimentation test can be
summarized in the following manner :
(1) It is an aid in differential diagnosis
and prognosis.
(2) A sensitive means of recognizing the
presence of inflammation and tissue destruc-
tion.
(3) The only guide in determining the
most favorable time for operative intervention.
(4) In pelvic inflammatory conditions we
consider a reading of 50 or less as a favorable
time for operation.
(5) The test is a more sensitive means of
indicating inflammatory changes than is the
white cell count or temperature curve.
(6) In malignancy the sedimentation cor-
responds with the degree of tissue involvement.
(7) In fibroids the test will show in what
cases we may expect inflammatory complica-
tion, for an uncomplicated fibroid shows a
normal sedimentation.
In conclusion, it is hardly necessary for me
to call attention to the importance of correlat-
ing the sedimentation reading with the history,
the clinical picture and pelvic signs. I merely
assert that it is easier to do a sedimentation
test than to make a blood count, and that you
will sret more information out of a sedimen-
tation test than from a blood count in the
presence of a latent infection.
This applies not only in gynecology but to a
variety of other pathologic conditions in other
branches of medicine and I would make a
plea at this time to the other services that it
be used routinely and they become convinced
of its value in their own branch of work. To
quote Dr. Polak: “The sedimentation is not
a panacea, it is valuable because a high read-
ing means infection — a low reading means
that infection can be excluded ; for the sedi-
mentation test never lies.”
I desire, at this time, to thank Dr. Yaguda
for his kind cooperation in introducing this
test as a routine measure in our hospital ; and
also Dr. Glass, who was assigned to this work
on our service.
THE ACUTE ABDOMEN*
John B. Deaver, M.D.,
Philadelphia, Pa.
I hope the experience of many years of
active work in study of the pathology of the
living, solving many riddles and disentangling
many alliances, may be of help to you in un-
ravelling some of the difficulties that concern
diagnosis and treatment of acute disease of
the abdomen. I will confine my discussion to
the “idiopathic” abdomen.
Before proceeding, let me remark that in
no emergency is clinical acumen a more valu-
able asset than in the “acute abdomen”, for
much as I value aid of the laboratory in the
diagnosis of certain diseases, I am free to
state that in acute abdominal disease, such as
a perforated appendix, perforated gall-blad-
der, perforated duodenal ulcer, ruptured ec-
topic pregnancy or a twisted pedicle of an
ovarian cyst, the laboratory has little if any
place, with exception of the blood picture and
the sedimentation test in acute pelvic infec-
tion, in the diagnosis ; but that diagnosis de-
pends most upon clinical facts and clinical ex-
perience, and since diagnosis to a large extent
affects prognosis, it is sound clinical knowl-
edge that counts in the end.
The first thing to be considered when con-
fronted with an acute abdominal condition is
to determine, if possible, the underlying cause,
the momentous question of operation, and
eventually the most favorable time for op-
eration. Sometimes all these questions can be
decided by the appearance of the patient; that
is, the evidence of hemorrhage, syncope, shock,
cyanosis ; the position of the patient, whether
fixed or restless ; the type of peristalsis ; the
history, if available, of previous attacks; the
nature of onset, character and site of pain,
presence of nausea and vomiting ; and the se-
quence of these 3 items — the site and the de-
gree of tenderness and the rigidity.
When approaching the bedside the common
causes of the acute abdomen should be borne
*(Read before the Atlantic County Medical So-
ciety at Atlantic City, Dec. 12, 1930.)
408
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1031
in mind. First and foremost is appendicitis.
Next in order are cholecystitis, perforated
peptic ulcer, intestinal obstruction, acute pel-
vic inflammation, ruptured ectopic pregnancy,
pancreatitis, twisted pedicle of an ovarian
cyst, diverticulitis, occasionally partial or
complete torsion of the great omentum, mes-
enteric thrombosis, and especially one should
not overlook a small lump at the site of one
of the hernial orifices, or at the site of a scar
the result of a previous operation, that may be
a strangulated hernia.
In spite of the fact that appendicitis heads
the list of causes of abdominal infection, it is
not at all unusual to be misled in the diagnosis
and to mistake it for some of the other dis-
eases, and vice versa. Every busy surgeon,
no doubt, has had the experience of opening
the abdomen for a supposed disease of the
gall-bladder or a peptic ulcer, to find that a
diseased appendix has assumed the role of the
upper abdominal condition, the other organs
being intact. Thus, an acute fulminating ap-
pendicitis may present the familiar signs and
symptoms of acute perforative cholecystitis or
perforating ulcer or acute pancreatitis. The
source of this error is due to the power of
mimicry of the appendix, which in turn rests
largely on the different positions the appendix
may occupy. An appendix in a position higher
than normal is especially prone to simulate
disease of the gall-bladder, and if perforated
at the base and the perforation is large, simu-
lates a perforated peptic ulcer. I have operat-
ed under these circumstances, believing the
case to be one of perforated ulcer, to find a
high-lying perforated appendix and a periton-
itis with no attempt at walling off, making me
fearful of further surgery; therefore, I closed
the wound, placed the patient on anatomic and
physiologic rest, and later, when the periton-
itis had subsided or become localized, I have
taken out the appendix. While the power of
mimicry of the appendix applies particularly
to the chronic ailment, it is not at all unusual
for a high acute appendix so closely to simu-
late an acute cholecystitis, especially in the ab-
sence of a definite history of gall-bladder dis-
ease, as to make it impossible to differentiate
between the two, at least not until the early
muscular rigidity has somewhat subsided, so
that by palpation the point of greatest tender-
ness can be determined and the diagnosis more
nearly approached. In the early stage of the
acute abdomen the rigidity is generalized, and
palpation, usually so significant a physical
sign, loses much of its value, so that the ques-
tion of immediate operation depends largely
on what can be learned by questioning the pa-
tient or his family, the patient’s general con-
dition, and last, but not the least, upon exper-
ience with similar cases. We all know, how-
ever, that operation at this early stage, before
peritonitis has advanced, will give the best
results when the peritoneal involvement is
usually confined to the site of the lesion and
the surgeon is able to protect the peritoneum
against contamination. In this stage, patho-
genic organisms are rarely found in the smears
taken at and beyond site of the lesion. Later
on, however, the infection becomes diffused,
especially if nature has not been able effec-
tively to place her barriers. Diffusion makes
for confusion and adds to the seriousness of
the situation. To operate in the presence of a
diffusing or a localizing peritonitis may be
likened to stirring up a hornet’s nest. Gen-
eralized abdominal rigidity is due to peritoneal
irritation, the fore-runner of peritonitis, while
when the rigidity is more pronounced at a
given point it is a sign of incipient periton-
itis. Rigidity, not general, together with cir-
cumscribed tenderness, is the finding in per-
forated appendix and perforated gall-bladder,
as against generalized rigidity significant of
perforated ulcer with the absence of decided
tenderness confined to a circumscribed area.
In ulcer the bacteriologic findings of smears
in the first few hours after perforation, at the
site of the lesion and beyond, are negative.
Here we have the explanation of the well-
known fact that practically all cases of per-
forated ulcer recover if operated upon early.
The exceptions are a perforated carcinoma-
tous ulcer and a perforated marginal ulcer. In
the former there is infection, the result of
necrosis, and in the latter infection the result
of the position of the ulcer in the jejunum.
Fortunately, as a rule, perforated peptic ul-
cer presents few diagnostic difficulties to any
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
409
one of average experience. The board-like
rigidity is so typical as to be indelibly im-
pressed on the average observer. The first
observer, as a rule, is the practitioner and it
is upon his prompt recognition of the situa-
tion and his prompt action in the emergency
that successful surgical treatment largely de-
pends— for surgery is the only treatment. Ex-
pectant treatment in these cases is much like
the instance in which the wife of a very sick
man said to the doctor: “Is there no hope?” — -
to which he replied : “It depends upon what
you’re hoping for, madam.”
The vast amount of profitable study which
has been accorded to diseases of the gastro-
intestinal tract, including peptic ulcer, has
brought with it many advocates of medical
treatment for the chronic ulcer. In my exper-
ience this has resulted in an increased number
of perforated ulcers. The internist and the
gastro-enterologist both seem to lose sight of
the fact that at least 15% of chronic ulcer?
sooner or later perforate ; that anywhere from
7 to 35% of gastric ulcers are the fore-run-
ners of carcinoma ; and that a small percent-
age of gastric and duodenal ulcer patients
bleed to death. This, to my mind, is a valid
argument against too prolonged medical treat-
ment of chronic indigestion with ulcer symp-
toms.
The chief pitfall in the diagnosis of per-
forating ulcer lies, as has already been indicat-
ed, in the mimicry of the appendix. The main
points of difference are in the history and the
physical signs. The history of ulcer is one of
long-standing indigestion while this is not so
in appendicitis. In the perforated ulcer seen
early, there is neither fever nor increased
pulse rate, as in perforated appendicitis. In
ulcer there is killing, unbearable pain ; while
the pain of appendicitis, though severe, is
more bearable. The ulcer patient assumes a
fixed position, while the appendicitis patient is
restless and rolls from side to side. In ul-
cer there is a general board-like rigidity of
the abdominal walls ; while in appendicitis the
rigidity is limited, as is also the tenderness
that in ulcer is general. In a few words, the
ulcer patient is the more desperately ill of the
two. To this audience all this may be like
carrying coals to Newcastle, but I am present-
ing this discussion in what I should like to
think a practical manner.
Acute perforation of the gall-bladder may
present symptoms similar to those of ulcer,
although the history of gall-bladder disease
should give the proper clue. In the absence of
this information, however, the differentiation
is not always clear — except that perforating
cholecystitis is rather unusual. Nevertheless,
it occurs with sufficient frequency to be borne
in mind in the presence of an acute abdominal
crisis. Besides the usual syndrome of an
acute perforation, jaundice is sometimes
present. In both acute and chronic cholecys-
titis jaundice is the result of cholangitis, us-
ually a lymph-borne infection. The differen-
tiation between acute perforating and acute
nonperforating cholecystitis is in the severity
of the symptoms and the physical signs, both
of which are more pronounced in the former.
Differentiation is important because while
acute non-perforating cholecystitis usually sub-
sides under anatomic and physiologic rest,
acute perforating cholecystitis demands imme-
diate operation. If acute perforating chole-
cystitis is not operated upon early it will rap-
idly develop a vicious, dangerous and too: of-
ten a fatal peritonitis, the severity of which
depends on the virulence of the pathogenic or-
ganism. In most instances it is the colon
bacillus, and not infrequently the infection is
streptococcal. In a very small percentage of
cases nature takes care of the infection by im-
prisonment, so to speak, so that the peritonitis
becomes circumscribed and the patient may
recover from the acute attack and may carry
on for a considerable time in reasonable com-
fort ; but, finally, operation becomes inevitable
and the findings then consist of a walled-off
abscess, the bed of which is the great omen-
tum, which contains stones that escaped at the
time of the perforation.
Acute pancreatitis, consisting of 4 varieties,
as I have been able to demonstrate at opera-
tion— the ultraacute, acute, subacute and the
focal — presents differential difficulties, in that
with exception of the subacute variety it oc-
curs without warning and is accompanied by
profound shock. It is probably more fre-
quent than is generally supposed and many
deaths from “acute indigestion” are no doubt
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
actually due to acute pancreatitis. Even when
the diagnosis of acute pancreatitis is made, it
is usually too late for successful operation be-
cause of the injurious effect of the escaping
powerful pancreatic ferments on the sur-
rounding tissues.
The ultraacute variety is rare and so rap-
idly fatal, because of the massive hemorrhage
around and within the pancreas and the lesser
peritoneal cavity, that there is little chance of
successful operation. The acute variety is
more common. In the acute there is hemor-
rhage beneath the serosa and within the pan-
creas. Subacute pancreatitis is probably the
most frequent of the 4 varieties of acute pan-
creatitis. In this, the pancreas is enlarged and
edematous, and occasionally a small amount
of fat necrosis is present. This is often diag-
nosed and operated on for acute cholecystitis.
A more frequent error, however, is the con-
fusion of acute pancreatitis with intestinal ob-
struction. Why this is so I am at a loss to
understand, as the differential points seem to
me so conspicuous. Acute pancreatitis, with
few exceptions, occurs in middle life or after.
The patient is usually stout, a heavy eater and
often a fairly heavy imbiber. The onset is
sudden and overwhelming. There is persistent
vomiting, which fails to yield to lavage, hic-
cough and cyanosis. The pulse is rapid, there
is marked abdominal distension, especially in
the epigastrium, rigidity of the abdominal
walls and hypoperistalsis or the absence of
peristalsis. In acute intestinal obstruction, on
the other hand, the pain is intermittent and
the pulse is of normal volume and rate ;
vomiting is temporarily relieved by lavage ;
peristalsis is stormy and there is no distension
until late in the disease. If vomiting persists
it becomes of fecal odor — an unmistakable
sign of what is going on. Unfortunately,
acute intestinal obstruction is not always
recognized in its early and most favorable
stage for operation. One reason is that so
often it follows a dietary indiscretion and is
treated with home remedies before the doctor
is called. The onset of sudden, sharp, colicky
pain, followed by sick stomach and vomiting,
is mistaken for severe bellyache. Giving a pur-
gative, as is sometimes done, is disastrous.
Unless the suffering is very severe more time
is lost by giving enemas, which even when fol-
lowed by a stool accomplish nothing but delay
in sending for the doctor, and when the doctor
finally sees the patient the picture will have
undergone a marked change and will have as-
sumed the second stage of obstruction. The
belly walls have lost their rigidity, abdominal
distension is marked and in some instances
coils of bowel are seen, although not so fre-
quently as in chronic obstruction, where the
abdomen presents the ladder-rung appearance.
Now the vomitus has the characteristic fecal
odor, there is hyperperistalsis, rapid pulse and
temperature. In the third state — the stage
of approaching dissolution — the pulse is rapid
and weak, the abdomen is greatly distended
and tympanitic throughout, the belly is either
silent or merely a tinkling peristalsis can be
heard, the pulsations of the aorta are ab-
normally loud and there is constant regurgita-
tion or fecal vomiting. Operation offers little
at this stage, being a last resort, yet it should
be done.
Acute obstruction due to intussusception or
to volvulus of the sigmoid should, as a rule,
be recognized early ; intussusception by colicky
pain, rectal tenesmus and mucoid bloody
stools, and, as a rule, the presence of a tumor
detected by abdominal palpation and digital
examination of the rectum ; volvulus by sud-
den onset of very acute pain immediately fol-
lowed by sudden and great distension of the
lower abdomen. I impress upon my interns
to think first, last and always of the appendix,
if it has not been removed, when seeing an
acute abdomen, and if absent to think next
of acute intestinal obstruction caused by ad-
hesions.
At this point we must again turn to the ap-
pendix. As already indicated, the mimicry of
this organ depends to some extent upon the
position it occupies. The term pelvic appen-
dicitis thus is self-explanatory. It is also
sometimes a very convenient diagnosis for
disease of the pelvic organs. Owing to the
close proximity and lymphatic relationship of
the appendix to the pelvic organs, it may be
difficult at times to tell exactly where the
trouble lies, or at least where it originated.
Nevertheless, differentiation between a true
pelvic appendicitis from suppurative condi-
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
411
tions such as acute salpingitis, salpingo-
oophoritis, twisted pedicle of ovarian cyst, and
sigmoidal diverticulitis, is essential, for upon
the diagnosis will depend the line of treat-
ment, and if surgery is indicated, the best
method of approach. Acute salpingitis, for
example, will subside under anatomic and
physiologic rest. The error of overlooking an
acute suppurative salpingitis can be avoided
by a careful history, vaginal examination,
making the sedimentation test, the presence of
a vaginal discharge, the relative tenderness in
the adnexal regions with perhaps some fixa-
tion of the uterus, the attempt to move which
by pressure against the cervix evokes pain,
and the presence of a small palpable mass to
both vaginal and rectal touch. An important
point in the history is the gradual onset, with
the pain in the lower abdomen, unless the les-
ion be a leaking or ruptured pus tube, in con-
trast to the suddenness of the appendiceal at-
tack. Bilateral abdominal rigidity with pain
referred to the left side and marked tender-
ness to deep pressure by 2 finger tips on the
outer side of the lower-third of the right rec-
tus muscle directed downward and to the left,
bespeaks pelvic appendicitis more often than
salpingitis. The history of a recent abortion
and of gonorrheal infection is decisive. Some
authorities depend on the sedimentation test
which in appendicitis is normal, and decided
in acute pelvic infection. I attach consider-
able importance to this test, popularized by
our colleague, Polak. Twisted pedicle of a
right ovarian cyst is often mistaken for acute
appendicitis. There is the same sudden onset
of abdominal or pelvic pain, nausea, vomiting
and more or less exquisite local tenderness
and rigidity. The distinguishing feature is
the presence of a palpable tumor, usually in a
low position. In view of the fact that opera-
tion is indicated in either case and also that
the appendix should be removed even if the
condition is ovarian, the clinical diagnosis is
not of primary importance. In a pelvic sup-
purative appendicitis, the route of approach
will depend on the condition and sex of the
patient and, if a female, her age. In the fe-
male, occasionally the best incision is one
through the vault of the vagina behind the
cervix ; while in the male much depends upon
how sick the patient is, the exact location of
the collection, whether above the pubic bone
or Poupart’s ligament or deep in the pelvis
and if fluctuation is evident to rectal touch.
The aim of the surgeon should always be to
open the abscess by extraperitoneal approach.
The symptoms of ruptured ectopic tubal
pregnancy, it seems to me, are so distinctive
as to be almost unmistakable. But I admit I
have been guilty of an occasional erroneous
diagnosis. The history is without doubt the
most important diagnostic aid. But this is not
always reliable. The similarities of the two
conditions, acute appendicitis and a ruptured
right tubal pregnancy, lie in the sudden pain,
tenderness and rigidity, together with the
evidence of shock and syncope due to the
hemorrhage. The association of tubal preg-
nancy and acute appendicitis, though rare,
should be borne in mind. Again, operative in-
terference is indicated; refinement of diag-
nosis is not essential if the best interests of
the patient are to be served.
An acute sigmoidal diverticulitis oftentimes
simulates an acute pelvic appendicitis. A point
in favor of the former is that the signs be-
gin in the left lower abdomen, in fact it is
often spoken of as left-sided appendicitis; the
pain later may or may not become general-
ized, and there is a history of antecedent pro-
nounced constipation and discomfort from
the accumulation of gas. Etiologically, the
disorder is rare in the female, occurring more
often in the male at or past middle life. The
physical examination is of much moment. Dis-
tinguishing points are: tenderness on the left
side that is more pronounced and superficial
as compared with right-sided tenderness in
pelvic appendicitis ; due to the distance be-
tween the appendix, when in the true pelvis,
and the abdominal wall ; and finding by rectal
touch of a mass or induration in the region
of the sigmoid.
If acute perforated diverticulitis of the sig-
moid is seen and operated on early, before
abscess formation has taken place, a transperi-
toneal approach is best. In the presence of
an abscess, however, especially if it is very
low down in the pelvis, it is better to make
the approach through an incision in the an-
terior rectal wall — or, if the patient is a fe-
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
male, through the vagina. But fortunately, in
nearly all cases of suppurative diverticulitis
the collection is above Poupart’s ligament,
where through an incision above the outer-
third of the ligament and carried upward and
outward, dividing the aponeurosis and sep-
arating the fibers of the external oblique
muscle, and cutting through the internal ob-
lique and the transversalis muscles, the col-
lection can be evacuated without opening the
peritoneum.
The other conditions I have mentioned are
rare but they must be thought of if we are to
sharpen our diagnostic acumen. Mesenteric
thrombosis is characterized by very abrupt
and acute agonizing pain immediately follow-
ed by abdominal rigidity.
Volvulus of the great omentum is only diag-
nosed at operation. Its clinical manifestations
are those of the acute abdomen in general.
When the torsion is complete the signs and
symptoms, as I have already stated, are those
of intestinal obstruction, but when incomplete
they may suggest acute appendicitis.
Right-sided pyelitis in the female is not
infrequently diagnosed as high-lying postcecal
or postcolic appendix. This is inexcusable,
if the surgeon is alert.
When discussing the acute abdomen I am
occasionally asked how to differentiate be-
tween right-sided pneumonia, right-sided
pleurisy — especially subdiaphragmatic — and
heart disease, all 3 of which may cause pain
referred to the mid-upper and right-upper ab-
domen. This is a pertinent question, and I
am always glad to make an attempt to answer
it. In the early, the developing, stage of
right-sided pneumonia or of pleurisy, the
question of a high-lying appendicitis very fre-
quently arises, and if operation is consider-
ed the differential diagnosis is all the more
important. In both pneumonia and pleurisy,
the former usually being ushered in by a chill,
there is pain on breathing, increase of pulse
rate and temperature, increased respirations,
the presence of a slight cough, as a rule, ab-
dominal rigidity and tenderness of the upper
right and mid-abdomen. Increased respirations
with or without respiratory discomfort or
slight cyanosis, especially in the presence of
a high leukocyte count, say 40,000, will cer-
tainly make the careful surgeon apprehensive,
to the extent at least of postponing operation
for some hours in order to await development
of physical signs. Portable x-ray examina-
tion, when this is feasible, is of moment. Per-
sonally, I have seen enough of these cases to
put me on my guard about advising surgery.
In subdiaphragmatic pleurisy the differentia-
tion, while not so difficult, is still difficult
enough to make one cautious. In cardiac dis-
ease with attacks of angina, the pain may be
referred to the epigastrium and to the upper
right abdomen. This, together with the fact
that there is a much disturbed circulation, may
suggest the diagnosis of an acute gall-bladder.
1 he surgeon of experience, knowing full well
that under anatomic and physiologic rest the
gall-bladder condition will, with very few ex-
ceptions, subside, will counsel against opera-
tion in such instances. The surgeon who has
a good working knowledge of general medi-
cine, particularly if he was a doctor before
becoming a surgeon, has the advantage of
erring less often than he who has not this
knowledge.
While in no way claiming any originality
or completeness for this discussion, I hope I
have succeeded in crystalizing in your minds
some of the essentials in the diagnosis and
treatment of the acute abdomen as they have
presented themselves to me in the course of
my work.
RUPTURED GASTRIC ULCER; ROLE
OF THE INTERNIST*
Edward C. Klein, Jr., M.D.,
Newark, New Jersey
Rupture of a gastric ulcer is not only the
most formidable of the acute complications
attending this disease but it is also of the
greatest concern to the internist because he is
usually the first to see the case. Prognosis
depends almost entirely upon his decision,
since cases submitted to surgery within 6
hours are expected to recover, whereas with
♦(Read as part of symposium before Surgical
Section of Academy of Medicine of Northern New
Jersey, Oct. 28, 1930.)
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
413
every hour of additional delay the outlook
darkens until there is scarcely any hope after
24 hours, notwithstanding that now and then
someone records a recovery. By ruptured ul-
cer is meant a perforation of all the anatomic
coats of the stomach into the free peritoneal
cavity and extravasation of its contents into
the peritoneal sac. The more gastric disten-
sion with food, the greater the danger. How-
ever, as long as the contents are sterile the
danger is minimized by early operation ; but
if there be a previous stomach infection the
general experience is that a serious peritonitis
will inevitably follow.
Diagnosis, as a rule, is easy. The first and
most important sign is sudden agonizing pain
in the upper abdomen. However, Stohr re-
ported a case in which the pains instead of
being in the classical position radiated to the
right shoulder, thus giving the impression of
gall-duct spasm. The pain which follows per-
foration has been described as one of the most
violent and atrocious forms of suffering
known. It often occurs after a heavy meal,
during work or after some trauma, with evi-
dences of peritoneal shock, fever and a leuko-
cytosis. In the very beginning there may be
no abdominal distension, merely board-like
rigidity. Very often temperature and pulse
show little or no modification at first but with-
in 6 hours, as a rule, the characteristic peri-
toneal facies appears followed by symptoms
of peritonitis with vomiting, distension, fever,
rigors, rapid pulse and shock. The appearance
of a patient in shock, yet with little or no
temperature and a correspondingly low pulse
rate, is an invaluable sign in early diagnosis.
Since only 45% of patients give a clear ulcer
history, one must rely on eliciting a story of
periodic digestive disturbances, of obscure or
atypical symptoms, with periods of euphoria
intervening. Reperforation occurs at times
and is apt to be overlooked unless one
keeps the possibility of such a contingency in
mind, the symptoms of aggravation being laid
to progressive peritoneal inflammation ;
Lewisohn has even noted a third perforation
of the same ulcer. In acute ulcer, fortunately
representing only 10% of perforations, there
may be no warning symptoms at all. Never-
theless, they constitute a serious contingency,
especially when silent perforation occurs. An
interesting case was recently reported by
Gregoire ; perforation of a gastric ulcer with
free fluid and gas in the abdominal cavity but
at the same time without any distinctive clini-
cal signs. The patient, a woman 35 years of age,
was able to walk to the x-ray department, 100
meters away from the ward, and it was only
after fluoroscopic examination had disclosed
presence of air in the peritoneal cavity that a
perforated duodenal ulcer was suspected. As
to whether the initial distress attending perfor-
ation is due to the giving way of the gastric
wall, or to irritation of the adjacent peritoneal
surfaces, there would seem to be no longer any
doubt. During the discussion of Gregoire’s pa-
per, Rouhier related 2 cases occurring in his
practice in which the operative findings showed
localized peritonitis before there had been time
to completely perforate all the walls of the
stomach. Guimbellot added 2 similar exper-
iences, and his first case is worth study from a
symptomatologic standpoint because of the in-
itial location of the pain ; a 40 yr. old man was
suddenly seized with severe pain in the right
lower abdominal quadrant, and vomiting last-
ing 24 hr. before the patient was submitted to
surgical intervention. The anterior surface
of the pyloric region was found to be covered
by the transverse colon. No perforation had
occurred but a whitish plaque of about 1.5 cm.
showed on the pyloric aspect, as well as a
similar one on the apposite colon.
The physical signs of localized tenderness
with board-like rigidity of the abdominal wall
becoming generalized with the progress of in-
fection, dulness in the flank or flanks indicat-
ing fluid in the peritoneal sac, augment the
diagnosis. In this connection, it is of im-
portance to remember the value of radiology
in the diagnosis of perforated peptic ulcer.
Vaughan and Singer demonstrated pneu-
moperitoneum skiagraphically in 63 of 72 pa-
tients having ruptured peptic ulcers as proved
by laparotomy. Another diagnostic point of
value in difficult cases or when radiographic
examination is not available has been brought
out by Neller. The patient lying flat upon
the bed, the finger of the- examiner is placed
over the naval while pressure is exerted and
released. When the naval is loosely closed
414
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
this pressure produces a peculiar crepitation
which indicates air in the peritoneal cavity.
In immediate postoperative care nothing, as
a rule, should be allowed by mouth for 24
hours. On the return to bed, pantopon gr.
1 3 is suggested to insure rest for some hours
after the operation; it is less apt to induce
vomiting than morphin. Eight to 10 oz. of
5 to 10% glucose in normal saline solution is
given per rectum every 4 hours. If these
rectal taps are not retained, the Murphy drip
may be resorted to. In formulating dietetic
management, the mode of surgical treatment
whjch has just been employed ought to be
considered ; for instance, in the simple suture
case, the patient’s condition being so serious
as not to warrant added risk of the supple-
mental short circuit procedure, it is wiser to
be cautious with mouth feedings. Half hourly
drinks of % oz. barley or plain water may
be allowed on the second or third day. On the
other hand, food deprivation must not be car-
ried too far as Carlson has shown that the fast-
ing stomach is never quiet. Ivy’s recent studies
in the experimental causation of peptic ulcer
in animals have shown that the mechanical
factor of strong muscular contractions is quite
as important as the acid factor. The justifica-
tion, therefore, for such feedings is that
strong gastric contractions are apt to occur
if the patient gets hungry, which might lead
to injury at site of the suture. Peptonized
milk 1 to 2 oz. hourly up to the fifth or
seventh day may be used until cessation of
nausea and vomiting. The gastro-enterosto-
mized stomach has seemed to me comparable
to the physiologic state of complete relaxa-
tion, as the rectum is after divulsion of the
sphincter ani, but by the fifth day gastric
motility has recovered again and food passes
through an unobstructed pylorus as well as
through the stoma. This is the time that the
ulcer bed begins to granulate and surely none
but the blandest food ought to be allowed for
the next 4 weeks. However, on questioning
patients with unsatisfactory end-results, one
finds that this rule is honored more in the
breach than in the observance. In my opinion,
it is necessary to determine at the time of op-
eration whether atony is present, for this is
the type of case that always has stormy post-
operative experiences and is apt to go on to
acute dilation. Careful gastric aspiration,
using a small Rehfuss tube, is often necessary
to remove the accumulating material and oft-
times at the end of the day will remove stag-
nant, decomposing food stuffs. Rectal feed-
ing should be employed exclusively under
such circumstances. Where marked dilation
of the stomach is found at the time of oper-
ation nothing should be allowed by mouth
for 2, 3 or more days. There is no danger of
strong gastric contractions to such cases be-
cause of the severely atonic state of the mus-
cular coat. Rectal and intravenous alimen-
tation will serve the patient's immediate needs.
Here again, repeated aspirations will prove
of value. This is all the more necessary be-
cause the material is usually in a state of de-
composition causing elevation of temperature
and uneasiness, often vomiting. In a case
recently reported by Dixon, aspiration was
done daily for 16 days and as much as 1000
c.c. removed at times. When there is per-
sistent vomiting, due to the attendant periton-
itis, and danger of recurrent hemorrhage or
where there is considerable postoperative dila-
tation, glucose solutions intravenously and
lavage with hot water 12CTF. will often tide
the patient over until rectal or gastric feedings
can be resumed. If rectal alimentation is em-
ployed, certain details must be observed. For
instance, peptone solution should not be made
stronger than 10-20%. If it is, irritation of
the mucous membrane occurs and defeats ab-
sorption. The same substances should not be
given every time. Von Leube showed that
the addition of pancreatic extract to the white
of egg enema resulted in much better absorp-
tion. Pancreatized diluted cream has been
shown by Straus to be very easily absorbed
through the bowel. Those having a disincli-
nation to retain the aliment can be helped by
adding a small amount of laudanum to the
mixture. The addition of lactose should not
be forgotten, because of the ease with which
this carbohydrate is absorbed. In general,
during the first few days milk will be suf-
ficient unless there happens to be a specific
allergic state. Right at this point it is im-
portant to determine from the dietetic his-
tory of the patient whether there is any food
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
415
allergy, especially in reference to milk or egg,
in order to prevent stormy reactions. Vallone’s
studies in anaphylaxis and gastric ulcer in
sensitized animals showed that healing of the
lesions is much slower. He concludes that
change in the quality of mucus secreted to-
gether with the changed constitution of the
cells of the gastric mucosa, and insufficiency
of antipepsin in these same changed cells, are
some of the conditions which account for the
failure of ready cicatrization. If these views
are correct the great importance of discover-
ing alimentary sensitization in some cases be-
comes apparent.
In the gastro-enterostomized patient the
prevention of 'jejunal ulcer must be consider-
ed from the time of operation. We all know
that the gastrojejunal ulcer at the line of
suture is, as a rule, due to faulty technic, but
in the typical jejunal ulcer the altered physi-
ology is a factor that is too often neglected.
On account of the excluded duodenal juices
either in whole or in part, the main bolus of
food enters the jejunum thoroughly mixed
with the acid chyme of the stomach. To coun-
teract this exaggerated acidity mild alkaliniza-
tion and soft bland food should be used for at
least a month. Small doses of calcium phos-
phate and carbonate are effective for this pur-
pose, but where there is a suspicion or a
knowledge of multiple ulcers, or a history of
many relapses, bismuth in large doses must
be added and seems more effective in bringing
about a symptom- free state. Furthermore,
the bismuth by its chemotactic action undoubt-
edly aids cicatrization, as has been shown by
the use of bismuth paste in the treatment of
refractory sinuses.
After the eighth day a regular “ulcer cure”
should be instituted. The ulcer patient has
an ulcerous proclivity as a defect in his con-
stitution. The only known way now to con-
trol that is by placing the body in as near a
state of health as possible. Since nearly all
perforating cases occur in individuals of poor
resistance, the general condition must be
raised in order to prevent possible reactiva-
tion or reperforation. The erethistic type,
which is distinguished by the greater tendency
to painful peristalsis and hyperacidity, should
be thoroughly atropinized and kept that way
for many weeks when only suture with in-
clusion has been practiced, for the simple
reason that the gastric muscle must be kept
as quiet as possible in order not to delay
cicatrization. In all cases where a peristently
high hydrochloric acidity continues, atropin
should also be used for its effect on the vagus
in lessening acid secretion. In these latter
cases, experience with much material indi-
cates that there are also extrinsic causes for
the continued hyperchlorhydria.
Continuous intensive alkalization of the
stomach is still employed to a considerable ex-
tent, notwithstanding that Hardt and Rivers,
in a study of 48 selected cases with peptic ul-
cer observed in the Mayo Clinic from April
1921 to April 1922, showed toxic manifesta-
tions following the alkaline treatment. Al-
though these findings were not positive, they
were nevertheless suggestive of the injury
that might result from the persistent alkalosis
resulting from such a method of therapy.
Recently, however, Westphal and Kuckuck
have shown that alkalinization with sodium
bicarbonate is a more serious affair than one
would suppose. Considering how long the
use of antacids has been in vogue, it is strange
that the baneful local effects have not been
disclosed before now. They noticed, as have
many others, that instead of the usual hunger
pain of ulcer, those who had been on large
doses of bicarbonate of soda eventually re-
turned complaining of a feeling of fulness and
weight in the epigastrium and belching of
gas. Fractional gastric tests showed an
achylia which in some cases was histamin re-
sistant. Furthermore, by the employment of
Berg’s method of interpretation of Roentgen
topography of the gastric mucosa, the folds
were found broadened and thickened to a de-
cided degree. Histologic examination of
specimens of the gastric mucosa removed at
operation showed the usual structural changes
of hypertrophic gastritis. Continued roent-
genologic observations on cases exhibiting the
broadened folds of mucous membrane were
made after cessation of the intensive alkaliza-
tion, and this method regularly showed a de-
cided reduction in breadths of the folds. The
induction of alkali-achylia is thereby proved
to be a serious therapeutic blunder in that it
416
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
replaces an ulcer with what is regarded in
some quarters as a precancerous disease. Ex-
act observations have proved that the heavy
alkalization is found to be followed by a cor-
respondingly heavy response of the acid
glands of the stomach and the continued
stimulation of them eventually leads to func-
tional or organic exhaustion of their secretory
activity. It, of course, gives relief and there-
fore is popular. But is it justified in view of
these observations ?
Another fact, that all of you must have
noticed who are in the habit of studying the
clinical and therapeutic history of ulcer cases,
is that patients recover on all sorts of dietary
systems. Consider, for example, those used by
Von Leube, Lenhartz, Sippy, Alvarez, Ja-
rotsky, Smithies, etc. The more material one
sees, the more the principles laid down more
than 20 years ago by Hans Eisner appear to
comprehend the philosophic reasons. They are
in brief :
(1) Caloric values must be sufficient to
properly nourish that particular individual.
(2) Daily volume should not be too large
nor too small in order to avoid contractions
from over distension on the one hand and
from hunger on the other.
(3) Nutrient material must be nonirritat-
ing, both chemically and mechanically. There-
fore, spices and roughage must be avoided.
(4) Articles comprising the diet should be
such as to combine easily with the hydro-
chloric acid. Herein lies the advantage of the
modified Lenhartz diet of milk, eggs and
meat. So then, to my mind, the successful
management of the diet of ulcer patients calls
for careful individualization. For instance, in
one case the only thing tolerated by a patient
was the old fashioned “mandelmilch”. Rectal
feedings had failed entirely, and the stomach
refused everything for 8 days excepting this
“mandelmilch”.
Recurrent postoperative ulcer is a stubborn
problem very rebellious to surgery, the patient
usually experiencing many revisions. Here we
have found that 20 weeks’ rest in bed with ap-
propriate dietetic and medicinal measures is
the only method offering real recovery to the
sufferer; always providing, of course, that the
operative mechanics have been properly done.
Indeed, the value of sufficient physical repose
in rebellious cases seems to have attracted
little interest. The usual period according to
the histories of patients coming in with re-
lapsing ulcer is one of 2 to 6 weeks. This
amount of time suffices in the usual run of
acute or superficial ulcerations, but is never
sufficient in deep or relapsing cases. The indur-
ation around an old ulcer often requires at least
10 weeks for absorption before cicatrization
commences. Anyone can verify this state-
ment by observation of cases submitted to
surgery. The reason is that the stomach is
never at rest. It can not be splinted like a
broken bone, but the respiratory excursions
can be lessened and slowed, fhus giving the
lesion such an amount of rest that the local
reparative powers can do their work. The
warrant for this view is the same as with the
heart, the lungs and other organs. Why not
give the stomach the same opportunity? Be-
sides, and this applies with especial emphasis
to old and rebellious cases, not only does
physical repose lessen the respiratory excur-
sion of the diaphragm, thus giving the stomach
more rest, but every one must have noticed
that ulcer patients are of a peculiarly nervous
type, characterized by nervous tension, and
that atropinization is often unable to reduce
the hyperchlorhydria. Providing that there
are no extrinsic causes for the continued hy-
persecretion of acid these same cases will
show a low acid curve after sufficient bodily
rest. There is no need of heavy alkalization
where sufficiently long physical rest is carried
out. And when these things are explained to
the patient together with the gravity of his
lesion there is seldom serious objection to
submission. All that has just been said ap-
plies with even more force to those trouble-
some cases that continue to have pylorospasm
even after the best of surgery. A personal
case had had 4 surgical revisions without the
slightest relief, but was entirely relieved by a
20 weeks’ rest cure. The same advice is
necessary in those cases of posterior ulcer
which invades the pancreas as well as in those
more rare ones that cannot tolerate any form
of alkaline treatment at all.
In conclusion, all ulcer patients, after sur-
gical intervention and discharge, should be
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
417
given active clinical supervision, not only
dietetically but otherwise as well fo’- at least
1 year. Then, after a symptom-free state
arrives, the patient must be impressed with
the necessity of avoiding dietary and other
indiscretions, of the need of sufficient sleep,
and of the avoidance of unduly hard labor. In
short, he must be reminded that he has an
ulcer diathesis and that his future depends
upon maintaining more than the average
standard of health.
ACUTE PERFORATION OF PEPTIC
ULCERS*
Royal A. Schaff, M.D.,
Newark, N. J.
In the whole field of abdominal diseases
there is no more sudden, dramatic or danger-
ous catastrophe than an acute perforation of
a gastric or duodenal ulcer. By such an acci-
dent a patient, apparently in good health up
to the moment of its occurrence, is felled as
if by a bullet; and, unless prompt and effi-
cient surgical intervention is instituted, his
condition progresses rapidly from bad to
worse until death almost invariably super-
venes within a few days. Upon early recog-
nition and immediate operation, the victim’s
life depends more than in all other abdominal
emergencies, not excepting ruptured tubal
pregnancy, acute pancreatitis, traumatic rup-
ture of solid viscera or even gunshot wounds..
In all of these, the percentage of recoveries
without operation will be considerably higher
than in the overlooked or neglected cases of
acute perforation of a peptic ulcer, in which
the mortality is almost exactly 100%.
It is therefore essential that, from time to
time, the subject be reviewed in order that
the general practitioner, as well as the sur-
geon, may constantly bear the condition in
mind, and be familiar with those symptoms and
signs which in the early hours, at least, make
its recognition usually so easy.
Classification. Perforation of peptic ulcers
♦(Read as part of a symposium at the Academy
of Medicine, Newark, October 28, 1930).
may be classified as: (a) Acute; (b) sub-
acute; (c) chronic.
In the acute variety, with which the dis-
cussion this evening will be primarily concern-
ed, the perforation occurs suddenly, com-
pletely and often without premonitory signs,
the contents of the stomach or duodenum
being discharged directly into the general
peritoneal cavity, Morison’s pouch, or the
lesser peritoneal sac, depending upon the lo-
cation of the ulcer.
In the subacute variety, perforation occurs
almost if not quite as quickly ; but, owing to
the small size of the opening, the emptiness
of the affected viscus and the fortunate dis-
position of the natural protective forces of
the peritoneum, extensive leakage into the
peritoneal cavity does not occur. In these in-
stances, the surgeon finds the opening plugged
with a tab of omentum or sealed with lymph,
making a cover for the ulcer and preventing
the extravasation of any considerable quantity
of stomach contents.
In chronic perforation the ulcer slowly but
progressively extends through all the visceral
layers, allowing ample time for development
of a plastic peritonitis at its base or for ad-
hesion of the stomach or duodenum in the
region of the ulcer to neighboring organs or
to the anterior abdominal wall. The leakage
is therefore slight and limited to a small area,
but it may lead to the formation of a peri-
gastric or subphrenic abscess.
As one might expect, the great majority
(90%) of acute and subacute perforations
are found on the anterior surface of the stom-
ach or duodenum, while only a few (10%)
occur into the lesser sac or retroperitoneal
tissues. On the other hand, however, of
chronic perforating ulcers, more than 75%
involve the posterior wall and lesser curva-
ture of the stomach.
Etiology. Perforation, either acute or
chronic, is a natural event occurring at some
time in the course of 5% to 28% of all cases
of peptic ulcer, according to different statis-
tical studies. Its etiology may briefly be said
to be that of peptic ulceration in general,
with, in addition, a greatly increased activity
of the ulcerative process, due to unknown
causes immediately preceding rupture, or to
418
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
the strain of over-distension or sudden exer-
tion upon a much weakened gastric or duo-
denal wall. The majority of cases are seen in
males in the third to the fifth decades, but
no age is immune.
Symptoms. The symptoms of acute perfor-
ation may be grouped under 4 heads: (a)
Antecedent; (b) premonitory; (c) early;
(d) late.
The antecedent symptoms are those of in-
digestion, of the ulcer type, often extending
over a period of months or years. A care-
fully obtained history will rarely fail to dis-
close definite subjective evidence of the ex-
istence of an ulcer, especially when viewed in
retrospect, but one does occasionally encoun-
ter a case which has been quite symptom- free
up to the moment of perforation. Even
then, however, upon being pressed, the pa-
tient will usually admit that he “may be
troubled with a little gas now and then”. Be-
cause of gravity of the patient’s illness, ques-
tions bearing upon the antecedent history are
often omitted. One cannot emphasize too
strongly the necessity for care in this par-
ticular, for an accurate history will not in-
frequently make obvious an otherwise uncer-
tain diagnosis.
Premonitory symptoms are often absent,
but, when present, they have great sig-
nificance. If a patient known to have peptic
ulcer begins to suffer in the present attack
much more than in the past, if the pain be-
comes more severe and less amenable to treat-
ment, if localized tenderness appears or be-
comes more acute, then are the danger signals
of impending perforation being flown and
then should surgical treatment be undertaken
to fore-stall approaching disaster.
In the early hours following perforation,
the patient usually exhibits a striking attitude
and appearance. He is most often found
lying in a position of fixed immobility, com-
plaining piteously of excruciating epigastric
pain and resenting the touch of the examining
hand upon the abdominal wall. The ashen
pallor, beaded brow, anxious facies, rapid,
shallow breathing and the prostration combine
to give him the appearance of shock, but in
one most important respect the picture is
incomplete. The circulation shows little if
any change — the pulse remaining slow, volume
full and blood pressure but little altered. The
body temperature is usually normal or slightly
below and, in common with the pulse rate,
rises only with the onset of peritonitis. The
abdominal muscles at once become inflexibly
rigid producing in thin subjects a scaphoid
abdomen.
With the lapse of a few hours the disease
makes rapid progress. The pulse rate and
temperature increase, muscular rigidity per-
sists, the abdomen becomes much distended,
vomiting occurs repeatedly, and the picture
thereafter differs in no essential respect in its
course and termination from that of acute
generalized peritonitis from any other cause.
Pain is the one constant symptom of acute
perforation. It is sudden in onset, excruciat-
ing in character and prostrating beyond ex-
pression in its effects. It is generalized
throughout the abdomen, but it is often
greater in the epigastrium, the right hypo-
chondrium, or the right iliac fossa, depending
upon the site of perforation or the point of
maximum accumulation of extravasated fluid.
It does not radiate and it is much aggravated
by motion or by palpation of the abdominal
wall. It is variously described by different
patients, but all agree upon its agonizing in-
tensity. It is said to rival in severity the pain
of coronary thrombosis or that of acute pan-
creatitis, and at times its violence is so great
as to cause sudden death.
Vomiting of stomach contents and, rarely,
of blood, occurs as an initial symptom in a
fair proportion of the cases, but it is not a
prominent feature until after the onset of
peritonitis. The shock so commonly spoken
of is much more apparent than real. True
shock connotes a grave change in the circula-
tory mechanism, which in the case of acute
perforation in the early hours, is peculiarly
conspicuous by its absence. Moynihan aptly
describes the patient as “having the appear-
ance of shock”.
Physical signs. Rigidity of the abdominal
muscles and tenderness upon palpation are the
only physical signs always present. The
rigidity affects all of the abdominal muscles
including the diaphragm which, in conjunction
with the distension of the stomach, causes the
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
419
rapid, shallow type of breathing usually noted.
It is board-like in character and generalized
throughout the abdominal wall, but often dis-
tinctly more marked in the region of the per-
foration or of the maximum accumulation of
extravasated fluid. Muscular spasm of the
same degree is not encountered in any other
condition except sudden and complete per-
foration of other hollow viscera due either to
ulceration or traumatism. It is remarkable how
rapidly and completely the rigidity disappears
following closure of the perforation.
Distribution of the tenderness follows
closely that of the pain and rigidity, its point
of maximum intensity often serving to locate
the site of perforation with considerable ac-
curacy.
Disappearance of liver dulness, when ob-
served, is a sign of the greatest importance,
indicating, as it does, the presence of gas in
the peritoneal cavity. It is quite constantly
noted in late cases, where it serves as one of
the most valuable points in the differential
diagnosis of the various forms of acute gen-
eralized peritonitis. In the early hours, how-
ever, this sign is so often absent that failure
to elicit it should in no way influence one
against the diagnosis of perforation. Elicita-
tion of the sign requires great care. With
the patient in a semi-sitting posture, percus-
sion is made in the right midaxillary line in-
stead of over the anterior surface of the liver
which is so uniformly practiced, and which is
so misleading in cases with marked tympanites.
A roentgenogram, taken with the patient sit-
ting up, will demonstrate a bubble between the
liver and diaphragm when any considerable
quantity of gas has accumulated in the peri-
toneal cavity. As positive evidence, this find-
ing is invaluable ; as negative, worthless, for
many of the early cases will have but little if
any leakage of gas. Incidentally, this pro-
cedure constitutes the only laboratory exam-
ination of any value in the diagnosis of per-
foration of peptic ulcers. It is not pathog-
nomonic, however, for a collection of gas in
the peritoneal cavity from any source will
give the same picture. The method should
be employed only as an aid in the diagnosis of
•doubtful cases as it involves loss of time and
additional handling of the already too sick-
patient.
It is impossible to overstress the condition
of the circulation in the first hours following
perforation. No other abdominal crisis leaves
the pulse rate and blood pressure so little al-
tered. The tranquility of the pulse with its
full volume and the sustained blood pressure
seem quite incompatible with the otherwise
obvious gravity of the patient’s condition.
Failure to appreciate and remember this most
vital fact has led to many disastrous errors in
diagnosis and delays in operation. Only the
recent writers, notably, Moynihan, Finney and
Babcock lay sufficient emphasis on the point.
All the older text-books mention a rapid and
feeble pulse as an early sign of perforation,
and the error is perpetuated in an article by
one of America’s leading surgeons in a work
on “Surgical Diagnosis” published within a
few months. One must remember that in-
crease in the pulse rate and elevation of the
body temperature occur only with the onset
of peritonitis.
Diagnosis. The typical early case of acute
perforation of a peptic ulcer presents no diffi-
culty in diagnosis to one who has seen the
condition once or twice before. The ante-
cedent history of indigestion, sudden onset
with violent pain and prostration, appearance
of shock with unaltered circulation and the
board-like rigidity of the abdominal muscles
make a clinical picture difficult to confuse
with any other abdominal emergency. It is
worthy of note that the junior intern on duty
in the receiving ward of the City Hospital
rarely fails to make the correct diagnosis in
this type of case. Only in the presence of
coexisting “acute alcoholic intoxication is the
diagnosis apt to be diffiuclt. In such cases it
may be quite impossible to arrive at a cor-
rect conclusion without an exploratory incis-
ion. Should the doubt arise, one must not
hesitate to operate at once, for an unnecessary
operation will do little harm, while a delayed
one may easily result in disaster.
Differential diagnosis. Although the typical
early case of acute perforation is easy of
recognition, there are many less obvious ex-
amples which require differentiation from
other emergencies, thoracic as well as ab-
420
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
dominal. Perforation has been mistaken for
everything ranging from renal colic to sun-
stroke, but as a rule, distinction need be made
between only a relatively few conditions. One
most often must distinguish between perfor-
ation and acute appendicitis, and the task is
not always easy. The question arises usually
as the result of perforation of a duodenal ul-
cer, the extravasated fluid from which first
fills Morison’s pouch, then runs down on the
outer side of the ascending colon, and finally
accumulates in some quantity in the pelvis and
right iliac fossa where it may produce ex-
quisite pain with locally increased tenderness
and muscular rigidity. The mimicry of acute
appendicitis may be complete except for pres-
ence of the generalized board-like rigidity and
the appearance of shock with unchanged cir-
culation and body temperature. The ante-
cedent history, story of the onset, presence
or absence of rigidity of the muscles of the
left upper quadrant and possibly the disap-
pearance of liver dulness, will usually suffice
to settle the problem.
Biliary colic with or without acute cholecy-
stitis may give rise to the suspicion of perfor-
ation, but here the sex, age and stature of
the patient, the history of previous similar at-
tacks, character and radiation of the pain,
ceaseless motion in the search for relief and
absence of the appearance of shock and of the
generalized muscular rigidity, should serve to
make the differentiation clear.
The onset of acute pancreatitis is often
quite as spectacular as that of acute perfora-
tion, but, again, the age of the patient, ante-
cedent history of biliary disease, very rapid,
feeble pulse, uncontrollable vomiting and early
development of an epigastric mass, together
with the less generalized and less inflexible
muscle spasm, will be helpful in distinguishing
between the conditions.
Acute intestinal obstruction affecting the
small intestine occasionally simulates an acute
perforation ; but the intermittent colicky type
of pain, prompt vomiting of stomach follow-
ed by intestinal contents, and absence of gen-
eralized rigidity of the abdominal muscles
should clarify the diagnosis.
In each of the other abdominal emergen-
cies, such as acute salpingitis, rupture of a
tubal pregnancy, rupture or twist in the ped-
icle of an ovarian cyst, intussusception, acute
gastro-enteritis, strangulated hernia and renal
colic, the syndrome is so characteristic that
the differential points distinguishing these
from an acute perforation should suggest
themselves without special elaboration.
Of thoracic conditions, only 2 are apt to be
confused with an acute perforation : Lobar
pneumonia, affecting the right lower lobe and
causing a diaphragmatic pleurisy, sometimes
produces severe epigastric pain and rigidity of
the muscles of the right upper quadrant of
the abdomen. In such instances, however, the
chill, high fever, rapid pulse and respiratory
rates, and perhaps a pleural friction rub,
should enable one to rule out the question of
perforation.
An occasional case of coronary thrombosis
in which the pain is referred to the epigas-
trium instead of following its usual distri-
bution, may bear a strong superficial resem-
blance to an acute perforation of peptic ul-
cer, but absence of the characteristic rigidity
of the abdominal muscles together with the
disorganized heart action, low blood pressure,
and early appearance of a pericardial friction
sound should enable one to recognize the true
state of affairs.
One other pitfall requires mention in pass-
ing. A gastric crisis of tabes dorsalis has
more than once resulted in operation for a
perforation which did not exist. One need
only remember the possibility of the existence
of such a condition to be able to exclude it
by an examination of the pupils and the knee-
jerks. Incidentally, these steps should be part
of the routine in the diagnosis of all surgical
conditions within the abdomen. The rare in-
stance of a perforation of an ulcer occurring
in a sufferer from locomotor ataxia cannot be
differentiated from a gastric crisis without op-
eration, unless one. is fortunate enough to ob-
serve the disappearance of liver dulness or to
find a gas bubble in the roentgenogram.
The late cases of acute perforation of pep-
tic ulcers may present insuperable diagnostic
difficulties. Often the most one can say is
that a generalized peritonitis of unknown ori-
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
421
gin exists. It is here that the close scrutiny
of a carefully obtained history may furnish a
clue to solution of the problem. At this stage
there are no manifestations upon which much
reliance may be placed. Perhaps the most
constant and trustworthy sign is the presence
of gas, free in the peritoneal cavity, as shown
by disappearance of liver dulness or by
demonstration in a roentgenogram of a gas
bubble between the liver and diaphragm. Even
such evidence is inconclusive, however, for it
merely proves the existence of a perforation
somewhere in the alimentary tract — a perfor-
ated peptic or typhoid ulcer, leaking cecum,
perforated sigmoid diverticulm or, perhaps,
even a gas bacillus infection within the peri-
toneal cavity. In such a situation the surgeon
is justified in making a small suprapubic in-
cision. The character of the escaping fluid
will then enable him to locate the perforation,
to which he may gain access through a second
incision appropriately placed, the first being
used for drainage purposes if desired.
Prognosis. The prognosis in an acute per-
foration of a peptic ulcer depends largely
upon promptness of the diagnosis and the
speed and skill with which operative treat-
ment is rendered. It is an emergency of the
first magnitude, admitting of nothing but
the least possible delay. When feasible, the
patient should be taken directly from the am-
bulance to the operating room to save time
and unnecessary handling. Patients operated
upon within the first 6 hours will nearly all
.recover, but after that time the death rate
rises about 3% per hour until at the thirty-
sixth hour it reaches practically 100%. Here,
if anywhere, may the mortality be said to be
that of delay. The tyro in surgery may suc-
cessfully close a perforation in the early hours
— the most skilfull will be powerless to stay
progress of the advanced case.
No cloud is without its silver lining, and an
acute perforation of a peptic ulcer may prove
to be a blessing in disguise, for it seems to be
an established clinical fact that a large number
of the fortunate survivors gain permanent
relief from their ulcer symptoms following
their return from the Valley of the Shadow.
Supplemental Note
Dr. Herbert A. Schulte and Dr. Robert H.
Hill have analyzed with meticulous care the
statistics of cases of acute perforation of pep-
tic ulcers treated in the Newark City Hospi-
tal in the period beginning January 1, 1920,
and ending December 31, 1929. During this
time 168 patients were observed, the diag-
nosis in each instance being verified by opera-
tion or autopsy. Of this number, 62 (37%)
died. The majority of the recorded previous
histories mention one or more symptoms in-
dicative of ulcer, such as epigastric pain or
distress. There are many examples of the un-
altered pulse rate and body temperature in
the early hours following perforation.
A correct preoperative diagnosis was made
in 120 cases, while in 27 instances the condi-
tion was confused with acute appendicitis.
Perforation of an ulcer was mistaken for
acute cholecystitis and acute intestinal obstruc-
tion, each 4 times ; acute pancreatitis, 3 times ;
renal colic and heart disease, each twice ; rup-
tured ectopic pregnancy, tuberculous periton-
itis, cancer of the stomach, influenza, lead
colic and constipation each once. There is
ample and convincing evidence of the need
for early operative treatment and, after care-
fully reviewing all of the available data on the
fatal cases, one is reluctantly led to the con-
clusion that earlier operation, greater gentle-
ness and speed, more thorough exploration
and better closure of the perforation would
have saved a definite number of those who
succumbed.
TREATMENT OF PERFORATED
PEPTIC ULCER*
Herbert A. Schulte, A.B., M.D., F.A.C.S.,
Newark, New Jersey
In considering the treatment of this condi-
tion we shall hold to the classification of per-
foration as given by Dr. Schaaf, i.e. acute,
subacute, and chronic.
Acute and subacute perforations are treated
identically and we will discuss these first. The
*(Read as part of the symposium at the Newark
Academy of Medicine, Oct. 28, 1930.)
422
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
treatment is surgery, which might be written
in large letters, with emergency emphasized in
even larger letters. There are few problems
which the surgeon has to face that demand
emergency measures more than perforation
of a peptic ulcer, and few conditions in which
delay of a few hours may make such a differ-
ence in the result. I should like to repeat the
statement made by Dr. Schaaf that “the .mor-
tality rate rises about 3% with every hour’s
delay after 6 hours”, therefore, it is a dis-
tinct blot on the records of my surgical ser-
vice to delay operation any later than is ab-
solutely essential to make provisional diagnosis
and preparation for the surgical procedure.
These patients are always seriously ill and
great care should be taken in transportation
to and in the hospital. It would be more
ideal to have them enter the hospital directly
to the shock room connected with the operat-
ing suite.
There can be no doubt that recovery by
medical treatment alone is possible in certain
forms of perforated ulcers for there are cases
on record of undoubted perforation where
surgery was not immediately available, but
where later operation proved the point. So,
patients may recover but their recovery can-
not be urged as a reason for the delay or with-
holding of surgical help in all cases, for the
possibility of spontaneous recovery, though
not denied, is yet so remote as to make it im-
perative to adopt operative treatment at the
earliest possible moment. Attention to the
lesser details in guarding the patient against
greater shock during the operation is exceed-
ingly important and maintenance of proper
temperature of the table and room, avoidance
of delay in the operating room, posture of
patient during operation, and a carefully
chosen and administered anesthetic may play
important parts in the ultimate results.
The upper abdomen is usually opened to
the right of the midline by an ample incision.
It has been suggested that because perfora-
tions of longer duration frequently create
diagnoses, especially of appendicitis, that in
these cases a small suprapubic midline in-
cision be made. Gas and the type of fluid en-
countered would be helpful in more accurately
locating the lesion. The upper incision could
then be made and the suprapubic incision used
for drainage purposes. On opening the peri-
toneum one encounters gas and fluid which is
a mixture of stomach contents containing
semidigested food particles and the secretion
poured out by the peritoneum as a protective
measure, and is not only sterile but actively
antibacterial. The ulcer is not always readily
found, but it is recognized by the escape of
gas and fluid and by a thick deposit of lymph
around it. If the perforation does not readily
present itself, a search should be made in the
region where it most frequently occurs,
namely, in the neighborhood of the pylorus
and along the lesser curvature. Remember,
that about 90% are on the more easily acces-
sible anterior surface of stomach and duo-
denum. It has been stated previously that in
about 10% of cases the site of perforation is
not readily found because the ulcer is situated
on the posterior wall and in these cases it is
necessary to open the lesser peritoneal cavity
and continue search of the posterior wall of
the stomach. An ulcer of the posterior duo-
denal wall will sometimes rupture into the re-
troperitoneal tissues and produce an edema
of the area, which serves as an excellent guide
in the search.
As soon as the ulcer is localized, the in-
volved part is drawn, if possible, well up into
the wound, and precaution should be taken
against further soiling of the peritoneum. One
must not neglect a careful search for other
ulcers, for there have been cases reported of
simultaneous or almost simultaneous rupture
of 2 ulcers. The surgeon is then presented
with the problem of procedure, and it should
be emphasized here that every case is a law
unto itself and the problem is to apply to this
particular case that particular form of opera-
tive procedure which in his judgment is most
suitable to the condition. It is bad practice
and worse surgery to attempt to adapt any one
course to every case. One must be guided by
the location of the ulcer, size of the area in-
volved, degree of chronicity and effect of
any procedure on the future function of the
organ ; always remembering that the operation
is an emergency procedure, and the patient a
relatively poor risk. Therefore, depending on
the factors involved, the ulcer may be cauter-
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
423
ized or excised before proceeding with re-
pairs.
There seems to be good evidence that an ul-
cer which perforates and heals does not recur.
If this is true in all cases, then treatment by
cautery or excision is a useless procedure and
time misspent.
For simple closure of the perforation, a
single stitch through all coats will suffice, or
a mattress suture, which is of particular value
where edematous tissue is encountered. The
site is then buried by infolding the stomach or
duodenal walls with double layers of con-
tinuous sutures. To make the sealing-off
complete, an omental flap is of great value.
Many surgeons recommend turning up the
great omentum to lie between the anterior
stomach surface and the parietal peritoneum.
If the stomach is full, as it frequently is, it is
wise to pass a stomach tube and empty it of
contents. A gentle lavage may also be per-
formed. Some authorities, Deaver for in-
stance, insist upon closure of the perforation
followed by gastro-enterostomy, as a routine
procedure, while others, headed by Moynihan,
practice this only when the exigencies of the
case demand it. Let me quote Moynihan on
this point :
“The question of the performance of gastro-en-
terostomy has excited great controversy. The fac-
tors which require consideration are many, and
they refer not only to the various attributes of the
ulcer in respect to position, size and lapse of time
since perforation, nor to the degree of peritoneal
contamination, but also and perhaps chiefly to the
experience, the judgment and the technical skill
of the surgeon. Statistics which have been furnish-
ed in large numbers do not help in the solution
of the problem.’’
Certain definite indications of procedure
can however be given. If the suture of an ul-
cer lying in the stomach or the duodenum has
caused a definite obstruction, then gastro-en-
terostomy will certainly be necessary or at
least extremely desirable. If obstruction
seems inevitable in the future because of the
contraction of a scar, or if there are other ul-
cers present, a short-circuiting operation must
be considered. A gastro-enterostomy per-
formed in a case of recent perforation does
not add appreciably to the danger of opera-
tion, but the mortality increases steadily in
cases operated on after 12 hours. The con-
dition of the patient in the late hours— 24 to
36 hours after perforation — is such that the
thought of prolonging the operation even for
a few minutes must be rejected.
Deaver has recorded a mortality rate of
only 6.8% in a series where gastro-enteros-
tomy was performed after infolding the ulcer.
For ulcers situated in the duodenum or
stomach near the pylorus, the pyloroplasty
as modified by Finney, with excision of the
ulcer, seems ideal for it has the added advan-
tage of not exposing other areas to contamina-
tion.
Differences of opinion are to be found
among surgeons of experience with reference
to the toilet of the peritoneum. Authority can
be found for almost any method that one may
employ. It is a serious question whether or
not more harm than good may be done by
attempting more than the removal of gross
food particles and other material readily ac-
cessible. Here, again, the element of elapsed
time enters. If more than 12 hours have
elapsed since perforation and if gross food
particles are free in the peritoneum, greater
care and longer time must be spent in ensur-
ing that all is clean. Moynihan recommends
hot moist sponges passed into all parts of the
abdomen, with especial care to the subdiaphrag-
matic areas, for the risk of subphrenic abscess
or spreading of a septic inflammation through
the diaphragm, giving rise to a pleurisy or
empyema, is by no means inconsiderable. Fin-
ney and others suggest flushing the peritoneal
cavity with hot sterile saline through multi-
ple incisions to be used for drainage. But this
procedure should be reserved for the severe
cases of longer duration.
The question of drainage is a debatable one.
Some authorities advise drainage as a routine
practice, others oppose it. After all, the
question of drainage can be decided only by
the surgeon himself in each case. The time
elapsed since perforation and the type of
peritoneal fluid must be the guides. It is stated
that if less than 12 hours have elapsed, drain-
age is seldom necessary. After 12 hours, it
is probably necessary to drain at least one-
half of the cases. If one drains at all, it is a
good rule to drain thoroughly. This means
multiple drains placed in dependent portions
424
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
as indicated and brought out through stab
wounds in the flanks and above the pubis, or
even through the vagina in the case of women.
Drainage through the incision is to be avoided
if possible. Rolled rubber drains in pairs are
preferable, split rubber tubing is often em-
ployed, but gauze is not advisable because of
its tendency to act as a plug. Early removal
of drains is to be encouraged.
The most dreaded complication during the
postoperative course of a perforated ulcer is
formation of a subphrenic abscess or exten-
sion of a septic process into the chest as an
empyema. These conditions must be recog-
nized promptly and dealt with accordingly.
The treatment of chronic perforation is also
definitely surgical, but the great need for
hasty intervention is not so imperative. In
these cases we find that there has been a limit-
ed area of peritoneal involvement, usually
fixing the ulcer to an adjacent organ, or a
well limited perigastric abscess has formed.
The same general principle governing the sur-
gical procedure can be used here as in the
acute varieties, but the type of operation em-
ployed will be the same as for any chronic
ulcer uncomplicated by perforation.
In reviewing the cases of perforated pep-
tic ulcers admitted to the Newark City Hos-
pital for the 10 years 1920-9, we have accum-
ulated a lot of statistics which are of doubt-
ful value, and if presented here I am sure
would be a bore. There are, however, some
figures which I feel might be of some interest
to you.
There were 106 patients who recovered,
operated upon by 24 surgeons ; 74 were op-
erated upon within 12 hours after perfora-
tion; 15 within 12 to 24 hours; 3 within 24
to 48 hours, and 14 within 48 hours to 14
days. In 2 surgical cases no perforation was
found, but all evidence suggested a ruptured
ulcer. In 72 cases, the surgeon infolded the
ulcer ; 7 ulcers were cauterized and 8 ex-
cised ; 13 posterior gastro-enterostomies were
performed. In 10 cases the appendix was
also removed. Only 5 cases were not drained;
these made uncomplicated recoveries, the av-
erage stay in the hospital being 19 days. In
19 cases stab wounds were used for drainage,
and 3 of these developed the postoperative
complications of subphrenic abscess. If these
3 patients whose hospital stay ran up to 73
days, be excluded, we found an average con-
valescence time of 20 days. Of 72 cases
drained through the wound either alone or
with stab wounds, 4 were complicated
by subphrenic abscesses. The average hos-
pital stay was 25 Rj days. There were 62
deaths ; 58 were operated on, and 4 who were
moribund on admission, and the diagnosis was
made at autopsy. In analyzing 58 deaths we
found that there were 6 cases in which no
perforation was found at operation but which
were definitely diagnosed “ruptured peptic ul-
cer” by autopsy or operative findings. In 3
cases the ulcers were cauterized ; in 3 excised ;
no gastro-enterostomies were performed ; 4
added removal of the appendix and in 1 case
jejunostomy was done. These patients lived
from 1 to 36 days, an average of 5-}4 days.
The causes of deaths were: peritonitis, 46;
peritonitis and evisceration, 2 ; peritonitis and
diabetes, 2 ; peritonitis and hemorrhage, 1 ;
subphrenic abscess, 2 ; postoperative pneu-
monia, 6; and 7 had some cardiac complica-
tion.
It is interesting to note that of the 58
deaths 16 were patients who had been oper-
ated on within 12 hours. The causes of death
in these cases: peritonitis, 6; peritonitis with
no closure of ulcer, 2 ; hemorrhage, 1 ; pneu-
monia, 3 ; cardiac, 4.
There were 12 deaths in cases operated on
12 to 24 hours after perforation; 12 cases,
24 to 48 hours, and 23 were operated upon
after 48 hours.
I wish to express my appreciation to Dr.
Robert Hill for his help in going over the
City Hospital records.
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
425
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J.
Entered at the post office at Orange, N. J., as seccnd-class matter
PUBLICATION COMMITTEE
HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J.
EDITOR:
HENRY O. REIK, M.D., P.A.C.S., Vermont Apartments, Atlantic City, N. J.
Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to
receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fact.
NOTE. — The transaction of business will be expedited, and prompt attention secured if:
All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to.
The Editor, Dr. Henry O. Reiic, Vermont Apartments, Atlantic City, N. J.
All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements,
or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication
Committee, (address above), Newark, N. J.
THE PASSING WESTWARD OF
OSMUN AND LAWRENCE
That small group of officials comprising
the Secretaries and Reporters of County
Medical Societies mourns the recent loss of
two members whose departure creates vacan-
cies difficult to fill. Lawrence, as a Reporter,
exemplified the adage that it is the busy man
who finds time always to perform the extra
task demanded ; he rarely failed to report
promptly the proceedings of his county so-
ciety. Osmun, as a Secretary, was in like
manner, a prompt, reliable and efficient
worker in the interests of his profession ; and
it was partly in recognition of his faithful
attendance upon meetings that he was last
year promoted to the office of Trustee in the
State Society.
The officers of the state organization and the
Editor of the Journal will miss Lawrence and
Osmun as keenly, perhaps, as will their as-
sociates in Ocean and Warren Counties.
ADVANCE NOTICE OF ANNUAL
MEETING
Owing to the near approach of the 165th
Annual Meeting of the Medical Society of
New Jersey, this issue of the Journal is limit-
ed somewhat in size and devoted in part to
publication of the Presessional Reports and
the Preliminary Program. In as much as the
Journal material must go to the printer by
the middle of April for appearance in the
May issue (made necessary by changing the
meeting date to the first week in June), and
the fiscal year of the Society does not end
until June first, it is difficult if not impossible
for some officials and committee chairmen to
prepare a satisfactory presessional report; i.e.
satisfactory to those who are doing the work.
For that reason, and because it would have
seriously damaged her schedule, we take the
responsibility for having excused the Field
Secretary from submitting such a report this
year, and trust you will be satisfied with the
Executive Secretary’s assurance that her re-
port in June will show an excellent record of
performance and accomplishment. Our own
report cannot be a complete one but will
cover most of the important items. The
Treasurer will probably have to resort to a
leaflet for distribution at the opening ses-
sion. The Welfare Committee Chairman
supplies his report, as the. committee’s work
is probably terminated for the year ; and we
shall include herewith as many other com-
mittee reports as may be received.
Monmouth County members are doing all
they can to make things attractive, even spon-
soring an “All Day Handicap Golf Tourna-
ment” for Wednesday, June 3, at the Asbury
Park Golf Club, to which men and women,
both, are invited. There will be prizes for
“low gross, and low net, 18 hole scores; and
special prizes for winners and runners-up in a
Scotch 4 ball four-some for men.
Do not overlook the fact that the Woman’s
426
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
Auxiliary is meeting at the same time and that
provision has been made for social entertain-
ment in which all may participate.
Come out and help make this Annual Meet-
ing an exceptional success. Make your hotel
reservations “right now”.
COUNTY SOCIETY AND HOSPITAL
REPORTS; WE PLAY NO
FAVORITES
On a number of different occasions the Edi-
tor has expressed the belief that much of the
material published by this Journal in its Sec-
tion, or Department, of County Society Re-
ports is of as great value to our readers, scien-
tifically, as the more carefully prepared ma-
terial presented through the channel of Orig-
inal Articles. That is notably true of the
Atlantic City, Bayonne, Elizabeth General,
Jersey City and North Hudson hospital staff
reports, and the Eye, Ear, Nose and Throat
Section of the Academy of Medicine of
Northern New Jersey. Our county society
reports are fundamentally for the purpose of
recording the transactions of such bodies, as
component parts of the organized profession,
giving incidentally abstracts of scientific
papers read, and of the discussions that fol-
low, at their meetings. It is in hospital staff
meetings that most clinical reports and dis-
cussions are now presented, and such reviews
of hospital work, including comparison of au-
topsy investigations with clinical records,
furnish the best kind of material for post-
graduate study.
Conceiving it to be one of the functions of
this Journal to record the professional work,
especially the clinical performances and scien-
tific achievements of the physicians of New
Jersey, we have constantly urged county so-
ciety reporters regularly to furnish us with
complete reports of all happenings at their
sessions and, whenever they considered any
paper on the program of sufficient merit to
justify its wider dissemination, to procure it
for publication in the Journal in full; and if
that could not be done, then to submit to us
an abstract of the paper. In like manner we
have repeatedly invited other local societies
and all hospitals to send us reports of pro-
ceedings. A glance at the last page of the
index to last year’s Journal will show to what
extent the invitation has been accepted.
Now, on several occasions, we have heard
that some member or group of members of
the state society felt aggrieved that his or
their city or county had been receiving less
space in the Journal than some other localities.
The Editor desires to dispose of such griev-
ance hv stating most emphatically that no par-
tiality whatsoever has ever been dispensed
from this office. The reason why the so-
cieties and institutions of Atlantic, Hudson
and Union Counties, and the one section of
the Academy, have filled so much space is
that they have alert and competent reporters.
The Editor does not “write up” those reports ;
he does curtail some of them editorially. And
he wishes to add the following message to all
whom it may concern :
If the proceedings of your county society,
or the doings of your hospital, are not re-
ceiving an appropriate amount of space in the
Journal, the fault lies in your own organisa-
tion. Send us as good reports as do the men-
tioned institutions and you will be accorded
the same amount of space. IV e play no
favorites.
STATUS OF STATE MEDICINE
The concluding letter of the series in which
we have reviewed so-called state medicine —
legally called national health insurance — ap-
pears in our travel talk this month. We have
endeavored to collect for you reliable informa-
tion concerning the laws and the working of
such laws in other countries and to suggest
the advisability of giving serious thought to
the problems involved, so that we may not be
caught unprepared if some radical legislation
appears, and that we may more intelligently
strive toward a solution of those unsatisfac-
tory conditions that possibly give rise to dis-
content and to threats of governmental con-
trol. May we now recommend that you read
carefully and ponder seriously upon the
3 special articles appearing consecutively in
the March, April and May Journals.
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
427
Special Article
MEDICAL TRAVEL TALK
The Editor Returns from Vacation
Henry O. Reik, M.D.,
Atlantic City
(Continued from April Journal)
Through the months of January to April,
hoth inclusive, we have written of observa-
tions made while vacationing last summer,
making use of such travel talk as a medium
for conveyance of oicked-up information re-
lating to the operation of state medicine in
Great Britain and France. Returning to the
editorial desk on the first of October, and
looking over accumulated journals, we were
amazed to find that during the previous 6
months not less than 40 articles dealing with
one or another aspect of state medicine had
been published in American Journals issued
by State Medical Societies ; many of those ar-
ticles being in the form of a State or County
Presidential Address. We knew that the
topic was a live one but had not realized that
quite so much concerning it had been written.
At first glance it appeared to have become
really a burning issue, but that was an un-
justified inference. Further investigation has
led us to believe that the apparently wide-
spread interest in this topic is limited to — at
least the articles mostly emanated from — of-
ficers of medical societies and that small
group of physicians that may be called “lead-
ers” of medical opinion.
It is very difficult, indeed, to ascertain to
what extent the profession at large is inter-
ested, but we can safely say that practically
every physician holding an organizational offi-
cial position that carries any degree of respon-
sibility, and every physician in the organiza-
tion’s ranks who has given serious thought to
the situation, is deeply concerned about
changes that have been effected or that seem
to be impending. Probably the condition is
similar to that which confronts us with regard
to governmental affairs. In political matters
— city, state or national — we find only a few
leaders or statesmen earnestly and intelli-
gently striving to solve problems of state ; a
larger number, but still all too few, that are
awake to the importance of some of those
problems ; and a vast congregation that re-
mains utterly indifferent. If we may from
our necessarily limited personal observation
draw similar inferences bearing upon this
point, we feel that a comparatively small per-
centage of American physicians are at pres-
ent reasonably well informed regarding the
economic changes that have been and are tak-
ing place in the practice of medicine; that a
larger percentage — fortunately a rapidly in-
creasing number — is showing some interest in
the situation and beginning to study these
problems ; but that considerably more than
50% of active members of the profession ex-
hibits only indifference. Whatever befalls the
profession will affect all of its members, and
what we fear is that indifference on the part
of the majority may result in something dis-
astrous to the whole number.
That feeling explains our decision to ex-
tend these travel talks to cover state medicine
reports from some other countries, so that in
the light of knowledge as to what has happen-
ed elsewhere we may become better prepared
to deal with our own troubles.
So, having reviewed conditions in England
and France let us collect what information is
available from other sources ; we wish it were
possible to accompany such data with an en-
tertaining round-the-world travelogue, but at
present can only supply material gathered
from various publications.
It would be natural to commence with a
consideration of state medicine in Germany
because that was the first nation to adopt com-
pulsory insurance against sickness ; back in
1883. Unfortunately, at the present moment
conditions in Germany are so topsy-turvy
that outsiders cannot with any degree of ac-
curacy estimate the situation. Prior to the
World War we were given to believe in a
general way that the socialistic medical laws
in Germany were highly developed and in the
main satisfactory to physicians and the people
alike. Since the war we have heard much
grumbling and neither the people nor the pro-
fession seems satisfied. Some of the discon-
tent may be attributable to the changed state
of affairs growing out of the governmental
revolution; some may arise from the post-
war period of bankruptcy and the slow re-
covery that is taking place in all professions
and general business 'throughout Germany;
but a large part of the trouble may be due to
faults inherent to the original plan, that have
been made worse by recent developments.
If we correctly understand it, the German
system has always been defective in some im-
portant respects ; for instance, that health in-
surance practice was not open to all qualified
physicians, and, that control of such practice
did not rest with a medical body but with lay
officials. At any rate, we are not able at this
moment to give out authentic information con-
cerning the working of state medicine in that
country, and it is appropriate to add here that
our state of knowledge is little or no better
428
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, I'J31
concerning Austria, Hungary, Bulgaria and
other countries embraced in the broad term
of “Middle Europe”.
Belgium was last year passing through the
same agony that France had previously en-
dured, in broadening the scope of compulsory
health insurance and the organized medical
profession (Federation medicale Beige) was
fighting the radical provisions of a law then
pending in the Senate, and was demanding
amendments that would, in effect, produce a
law comparable in the main to the one proposed
by the British Medical Association. The last
information we had relating thereto was that
the original Bill had been withdrawn and a
new one— granting the requested amendments
— introduced.
Holland, which, like all other European
countries, has long had voluntary health in-
surance, passed in 1930 into the group of 24
nations that provide for compulsory insurance
of employees or wage earners of limited in-
come ($720 for single and $1080 for married
persons). We usually give the Dutch credit
with exercising a deal of “common sense”,
and it is noteworthy that under the Nether-
lands law physicians have themselves organ-
ized “Association Funds” (their name for the
health insurance companies), and thus control
the situation so well that any member of the
national medical association is eligible to treat
such insured persons, and all shall be paid
regulation fees for such services.
Among the Scandinavian countries, Den-
mark is reputed to have the most satisfactory
scheme of insurance against sickness — a
scheme which links health insurance with
other “necessities of life”, especially provision
for invalidism and old age pensions, and
which requires “repayment of all expenses in-
curred by public assistance, if in the future
the individual can”.
Russia comes to mind now whenever one
thinks of any state social problem ; and con-
cern for the people’s health is no exception
to that rule. In the April Journal, page 361,
we reviewed Chamberlin’s book on Soviet
Russia, in so far as the author referred to the
practice of medicine. Of much greater value
to us, as physicians, is a small book — Health
Work in Soviet Russia — published among the
Vanguard Studies of Soviet Russia (price 50
cents), edited by Jerome Davis of Yale Uni-
versity. The book was written by Anna J.
Haines, a trained nurse, graduated from the
Philadelphia General Hospital, who has spent
a great deal of time in Russia since 1917 doing
relief work, and establishing a Nurse’s Train-
ing School in Moscow, under the auspices of
the American Friends Service Committee.
Miss Haines’ work should be doubly inter-
esting to us because she is a product of New
Jersey; having been born in Moorestown and
lived a goodly portion of her life in this state.
We recommend as strongly as possible that
you purchase and read Miss Haines’ book ; it
is worth many times the small investment re-
quired. Here, of course, we can only provide
you with selected portions to indicate what is
happening to medical practice in Russia.
In the first place, both these authors, Cham-
berlin and Haines, agree in opinion that Lenin
was fotunate in the selection of Dr. Semashko
for Commissar of Health, and that Stalin has
been wise in keeping that officer in charge of
all health affairs. It appears also that the
Commissariat of Health has made greater
substantial success than any other department
of the Soviet regime.
Nikolai Alexandrovich Semashko was a
plain, country boy, born in the Orlov district
and educated through his youthful period in
the nearby schools. Country life under primi-
tive conditions and among the peasants de-
veloped his rugged health and strength and
his understanding of and sympathy for suf-
fering humanity. Country origin probably
accounts also for his characteristics of self-
reliance and practical ability to deal with
emergencies. Before his schooling was finish-
ed, the death of his father compelled the boy
to procure his university education by his own
efforts. His independent spirit got him into
trouble with “the authorities” during his stu-
dent days in Moscow, although he was never
a populist nor violently radical, and he seems
rather to have been forced into socialism by
a chain of circumstances. Banished from
Moscow for a time, he completed his medical
studies at Kazan University, where he met
Rykov. later to become the Soviet Prime Min-
ister, and at Geneva, where he met Lenin.
When the revolution occurred he returned to
Moscow, from a country practice somewhere
in the Balkans, and was chosen to serve as
Director of the City Health Department. His
reorganization of what constituted “a jumble
of private hospitals without funds, a few
wretchedly equipped public hospitals and a
dwindling staff of disgusted doctors and
nurses” attracted Lenin’s attention and when
the Soviet government moved to Petrograd
he was asked by Lenin to draft a public health
scheme on a nation-wide scale. His present
official position, as Commissar of Health, cor-
responds to that of a member of the Presi-
dent’s Cabinet — what would be called at
Washington “Secretary of Health” if we had
such a cabinet post ; to that extent, at least,
Russia is more advanced than the United
States.
Miss Haines gives us a detailed description,
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
429
with explanatory diagrams, of the health de-
partment organization, of the present state of
medical education, including the full cur-
riculum for medical schools and nurses’ train-
ing schools, and points out many difficulties yet
to be conquered in the vast scheme outlined.
Evidently much has been done but much re-
mains to be done, and as in all other divisions
of the new Russian government it remains to
be seen whether the idealism of Soviet leaders
can be transmuted into successful practical
realism.
The Commissariat of Health controls
everything and everybody associated with the
prevention or cure of disease, acting largely
through or in cooperation with the All-Rus-
sian Medical Workers’ Union, whose mem-
bership embraces medical personnel from the
august super-specialist to the lowly hospital-
ward scrub woman. The following sentence
quoted from the historic sketch of this move-
ment has a familiar sound; i.e., “Of all the
groups of medical workers, the doctors were
the slowest to see the advantage in an asso-
ciation which would include them on the same
footing with other workers for the people’s
health.’’ The Russian Medical Association
fought state medicine in general and resisted
all overtures for affiliation made by the Medi-
cal Workers’ Union from 1917 to 1920, at
which time it was forced by legal procedure
to surrender; securing, however, by way of
compromise, the privilege of retaining its own
organization for scientific purposes.
Now, a few words as to the aim of soviet-
ized medicine and the accomplishments so far
recorded. Semashko published in 1926 an
essay on the Foundations of Soviet Medicine,
in which he declared: “Soviet Government is
a government by the masses in the cities and
the country. This fundamental fact deter-
mines the entire character of soviet sanita-
tion and medicine. The health of the workers
is the responsibility of the workers them-
selves. The nationalization of medicine does
not mean, as some think, the closing of all
private hospitals and prevention of all private
practice, but the actual socialization of medi-
cine ; the taking over by the state of the re-
sponsibility of providing for everyone, at his
earliest need, free and well-qualified medical
treatment. Only then will disappear, like a
shadow before sunlight, all private hospitals
and all commercial private practice. This is
the perspective of communist medicine.”
The goal is to be achieved by application of
5 basic principles :
( 1 ) The unification of medicine.
(2) Accessibility of medical aid to all citi-
zens.
(3) Medical treatment by qualified per-
sons.
(4) Free medical treatment for all citizens.
(5) Emphasis on preventive medicine.
That does not appear to be a very terrify-
ing program; indeed, with the exception of
item No. 4, it sounds not unlike an American
State Medical Society Welfare Program. One
other significant variation is found in an ac-
companying explanation that: “The present-
day Russian considers physical health as im-
portant a factor in life as education. There-
fore, medical service has been put in the same
category as the public school system, the state
aiming to provide both for practically all
citizens.”
Among the results so far attained we note
some interesting features :
(1) Limiting the working day of physi-
cians to 6 hours, and the opportunity afforded
them to carry on research work or any avo-
cation they please during their ample leisure
time.
(2) Free diet kitchens to which the physi-
cian may send patients who require scientific-
ally prepared food, just as they are sent with
other prescriptions to the pharmacy for medi-
cine to be furnished freely.
(3) The formal school life of children be-
gins with the kindergarten, to which applicants
are admitted after the age of 3 years. The ma-
jority of children enter public schools at the
age of 7. and upon entrance they are given a
thorough physical examination by physicians
trained for and assigned especially to this
work. Then, these school physicians are ex-
pected to treat, or send to specialists, all chil-
dren exhibiting defects that can be remedied ;
so that there is prompt correction of all faults
that might handicap the child, and there is
no wasted energy or loss of time such as at-
tends our own school inspections.
(4) Health and sanitation are taught ob-
jectively in the schools and the children learn
to assume responsibility for- personal and pub-
lic health.
(5) Special schools or classes are being
provided as rapidly as funds become available
for education and care of mental defectives or
those whose poor vision or hearing prevents
them traveling along the standard education
route.
(6) Campaigns against venereal diseases
and tuberculosis are well organized and every
facility for treatment is offered the victims of
those diseases. Special “night sanatoriums”
have been opened for the reception and care
of persons with incipient tuberculosis who
must, nevertheless, work during the day ; this
is an innovation which is said to be producing
surprisingly good results.
430
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
(7) The Insurance Fund pays full salary
to women for the 6 to 8 weeks of absence
from work before and after child-birth.
(8) An allowance in place of salary is
awarded to any worker during a protracted
illness, but this does not encourage malinger-
ing because it is limited to about 20% of his
regular salary.
(9) Since the physicians have accepted the
“new order of things” formerly famous
specialists have gradually been restored to
their old university and institutional positions,
regardless of their political beliefs; Pavlov,
for instance, is chief of the Institute for Pre-
ventive Medicine, and Speransky directs the
Institute for Protection of Motherhood and
Infancy.
(10) Incidentally, and surprisingly, distinct
propaganda for specialization is being carried
on among young physicians, urging them to
continue their studies and investigations along
special lines, and offering assistance in post-
graduate work; a striking contrast to most of
the talk in this part of the world, and another
interesting experiment to watch. It would
certainly be an ironic result if higher special-
ization should prove to be the solution of our
troubles arising from the increase in number
of specialists.
In her concluding remarks about sovietized
medical practice, Miss Haines says :
“Russia’s nationalized health system offers
one method of solution, neither more revo-
lutionary nor more expensive than our public
school system. We may not care to adopt this
solution but it can do us no harm to watch it.”
Coming now to the Western Hemisphere
we find Chile the only South American coun-
try so far listed as having adopted compulsory
health insurance — and of that law we regret
to say we know nothing— though Brazil and
the Argentine Confederation are considering
the matter, and Canada, in North America, is
on the verge of accepting state medicine.
In 1928 the Canadian national government
was asked to adopt some form of health in-
surance, and with that request was linked the
question of insurance to cover unemployment.
More attention was paid at the time to the
subject of employment, and then the Depart-
ment of Justice ruled that control of health,
like education, belonged to the provinces — -not
the nation ; a decision of importance to us
because, by comparison, we believe in the
United States that control of health matters
and the practice of medicine is a “state’s
right” problem. In consequence of that rul-
ing, the matter of health insurance was re-
ferred to the several provinces, and during
the past 3 years extensive and intensive study
of state medicine has been made by the pro-
vincial legislatures of Alberta. British Colum-
bia, Ontario and Saskatchewan. Through the
courtesy of Dr. W. Harvey Smith, Presi-
dent of the Canadian Medical Society,
we have had the privilege of reading the
records of the preliminary investigation by a
Royal Commission of the Canadian House of
Commons, and reports of the studies made in
Alberta and British Columbia; all very in-
structive documents.
It looks now as if the greater part of Can-
ada will adopt a plan of health insurance simi-
lar to that of Great Britain in the immediate
future. President Smith has advised the pro-
fession to recognize its responsibilities and to
devise plans for placing medical service on a
par with medical science, saying :
“The state, having granted the medical pro-
fession legal authority to control licensure
and to pass upon the qualifications of men
seeking authorization to practice, must un-
questionably possess the right to exact a
quality of professional skill and service that
will meet the needs of the age, and to require
adequate facilities for their distribution to
every section of the community. If corporate
medicine cannot or will not recognize and
meet the demands so insistently made for the
development of a system under which compe-
tent medical aid will be available — for rural
districts especially— no protest can be raised
if governments or municipal bodies take steps
to inaugurate a system of medical service of
whatever type and character may seem best.”
And now, at last, we return from this
theoretic voyage to foreign countries and are
confronted by conditions at home which seem
to demand some consideration with relation to
the necessity for opposing, or accepting and
guiding, state health insurance — otherwise
known as state medicine. As has been point-
ed out, nearly every other nation on earth has
either voluntary or compulsory health insur-
ance for those citizens who earn less than
$1200 a year; and it seems highly probable
that the few nations yet depending upon vol-
untary insurance will change to the compul-
sory form within the next few years. The
possible advent of state medicine into some
one of our states is by no means a new
thought ; its coming has been repeatedly pre-
dicted, promised or threatened. It does, how-
ever, seem to be at this moment more im-
minent than ever before ; an opinion based
upon the fact previously referred to, i.e., that
throughout our country those who are most
closely in touch with current events believe
that state medicine is due to arrive shortly
unless the profession can forestall it by sup-
plying something in lieu thereof — some im-
provement on present methods that will
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
431
satisfy the demand for better and cheaper
service to the mass of citizenry.
In support of that opinion let us remind
you that for the third successive year the
Legislature of Massachusetts has been pre-
sented with an Act to create a department of
public medicine and health for the purpose of
furnishing a free and complete medical ser-
vice to the people of the commonwealth of
Massachusetts, patterned upon the bureau of
medicine and surgery of the United States
Navy.
That Act will probably not become a law
this year but it is a noteworthy fact that each
year it has gained in the number of adherents
despite determined opposition on the part of
the medical profession ; and its author tells us
he is encouraged to believe it will ultimately
be adopted. Further, we may direct your at-
tention to an Act now pending in the New
York Legislature: an Act which covers the
entire field of health insurance, unemployment
insurance and old age pensions. Again, we
feel certain this proposition will be defeated
this year ; but, what about next year or the
year following? These are but single instances,
but they may be considered as very definite
indications of the direction of the wind; and
they are of special import because they have
appeared in 2 of the most conservative and
most important states in the Union, and be-
cause neither Act emanated from a “radical”
source ; one was drawn by a thoroughly re-
putable physician, and the other was sponsor-
ed by a legislator in good standing— whether
or not aided by a physician we do not know.
On our desk there are 28 original articles
that appeared in state medical society Jour-
nals between May and October 1930, articles
not searched for but which were observed in
the routine course of inspecting the tables
of contents as exchange copies passed through
our hands, all dealing with this question of
prospective state medicine. Among the au-
thors of those articles we note 3 Ex-Presi-
dents of the American Medical Association ;
7 presidents of state societies ; 2 presidents of
county societies ; and the others are all men
of orominence in the profession; no “reds”,
no paid writers, no one “with an axe to grind”
—but each and everyone speaking in the in-
terest of his medical confreres. We may add,
too, that these writers represent all sections
of the nation from Maine to California — in-
cluding, as it happens, both those states.
We will not bore you now with lengthy ab-
stracts from those articles, but to show that
there is no material difference of opinion be-
tween physicians of the east and the west, the
north and the south, who are awake to the
situation, and that there is among them a uni-
versal demand for preparedness, let us refer
briefly to 3 or 4 articles arising from widely
separated points.
Dr. S. H. Boyer, President of the Minne-
sota Medical Society, said: “What the attitude
of the medical profession shall be in relation
to the changes taking place affords food for
serious thought. That paternalistic encroach-
ments have taken place is only too apparent.
* * * The movement appears to be well nigh
world-wide in its scope and its tentacles are
reaching hungrily into our own country. It
has gathered such impetus now that only a
solidly organized and militant profession will
be able to ward it off or so modify it as to
eliminate its most pernicious features.”
At the Annual Meeting of the California
Medical Association, April 28, 1930, the
Chairman of the Committee on Medical Eco-
nomics, reporting to the House of Delegates,
deprecated the lassitude of the major portion
of the organization and scolded them for scant
courtesy shown another member who had
spent 2 years in study and preparation of a
'report upon economic conditions. In conse-
quence, in the July issue of the State Society
Journal (California and Western Medicine)
you will find 3 excellent papers by Drs. Rex-
wald Brown, of Santa Barbara, John H.
Graves, of San Francisco, and John C. Rud-
dock, of Los Angeles, reviewing the whole
subject.
W. G. Richards, of Billings, Montana, says :
“The danger of our present attitude is that
while we stand off and quibble the public may
take the matter into its own hands and im-
pose upon us some scheme of its own de-
vising.”
C. A. Harper, President of the Wisconsin
Society, says : “These facts strongly empha-
size a popular demand for certain changes
that will comply, more or less, with the wishes
of the general public. Is it wise for the medi-
cal profession to remain indifferent to the
problem while these agencies are developing
certain lines of activity, or would it not be
far better for the medical profession to ap-
preciate the evolution that is now taking place,
and become a prominent factor in guiding
these various lines of procedure?”
From the New York State Journal of Medi-
cine (Dec. 1, 1930, page 1424) we quote part
of an editorial written by Dr. William H.
Ross, President of the New York State
Medical Society, referring to the program of
the Annual Conference of State Society
Secretaries : “It indicates that the day of iso-
lation in medicine is over and that medicine
must soon undertake a self-appraisal of its
own organization to see if its own public
medical relationships are such as to enable it
432
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
to make proposals for the solution of unsolved
and unmet public medical service problems,
chiefly just 2 — the availability of medical
knowledge for limiting illness, and provision
for adequate medical care at a cost that can
be met without involving the individual in
debt from which he can hardly ever recover.
It is the obligation of medicine to propose
methods for these things, and, also, to work
out a solution of how the doctor may be paid
for his services to the indigent or near in-
digent, either in private practice or hospital.
* * * There may come another revolution in
medical practice, as it has come in the past,
as the result of great social needs and social
changes; and who knows that it is not be-
ginning? We may be nearer than we know
to such things as unlimited old age pensions,
provision for adequate medical care by the
state, and the inclusion of sickness benefit in
Workman’s Compensation and Health Insur-
ance as in other countries. It should make us
think !”
These Things "Should Make Us Think”
That is the note upon which we would close
this series of letters.
Medical Ethics
PATIENTS MUST NOT BE
NEGLECTED
John Hammond Bradshaw, M.D., F.A.C.S.,
Orange, N. J.
A physician is free to choose whom he will
serve. He should, however, always respond
to any request for his assistance in an
emergency or whenever temperate public
opinion expects the service. Once having un-
dertaken a case, a physician should not aban-
don or neglect the patient because the dis-
ease is deemed incurable; nor should he with-
draw from the case for any reason until a
sufficient notice of a desire to be released has
been given the patient or his friends to make
it possible for them to secure another medi-
cal attendant.
— Sec. 4, Principles of Medical
Ethics, A. M. A.
We should never forget we are dealing not
only with the sick but with human nature and
sometimes the human nature we treat is worse
than the disease that accompanies it. If we
attempt to treat the disease alone we are in
trouble and the patient does not get the full
benefit from our treatment. It often takes
more skill to treat weak human nature than
a weak stomach. What the patients some-
time forget is that we are human beings our-
selves.
A few years ago the press was full of com-
ments upon a case where allegedly, in one of
our cities, a patient had tried in vain among
more than 20 physicians to secure any one of
them to respond to his call. Like most of
such reports, when the story was investigated
it was found to be not only greatly exagger-
ated, but mostly false. But, the story having
been spread about in the papers, many people
had believed it to be true.
Years ago, the writer remembers a man in
his office who boasted that he had never paid
a doctor’s bill in his life, because if one doc-
tor refused to take the case there were al-
ways several who would be ready to respond ;
and probably he was right. Do we mark this
as a credit or a discredit to the profession?
Just as the physician should be free to
choose whom he would serve, so should the
patient be free to choose whom he desires to
treat his case. This needlessly often leads to
wailing and gnashing of teeth. Much enmity
and harsh criticism of our fellow-man can be
avoided if we will all have a heart-to-heart
talk with each other about our differences.
Personally, I have never known a physician
to abandon a case because he considered it in-
curable ; but I have known many instances
where, after he had expressed an honest opin-
ion that he had done all that he could, the pa-
tient had secretly slipped into the case other
doctors who, not being quite so honest, had
seemingly worked the case for all it was
worth, even up to the bitter end — even giving
the family and patient the idea that “if only,
etc.”, much to the discredit of the first physi-
cian. But doctors are no more perfect than
men in other professions, and we have even
heard of some lawyers doing shady things!
After some especially unkind and uncalled-
for treatment, on the part of the patient, to a
conscientious and faithful physician — for a
sick body often makes for a sick mind — it is
only human nature for the doctor to exclaim
to himself that he “will never make another
call”, and he can legitimately do this and re-
tire from the case if he sees to it that he
makes it possible for the family to secure the
services of another physician.
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
433
Collateral Reading
REVIEW OF SOME MEDICAL BOOKS
During the past 6 months we have received
complimentarily from the medical book pub-
lishers a considerable number of new books
for placement in the library of the Medical
Society of New Jersey. Pending provision
by the society of a suitable place for housing
its library, and proper facilities for a reading
room available and convenient to all our mem-
bers, we have placed these books in the
Library of the Atlantic County Medical So-
ciety at the Atlantic City Hospital.
The Journal has not space for elaborate re-
views of all these books, so we can only ex-
press the thanks of the State Society to the
donors and in listing the books make brief
comments upon the character and contents of
a few books that merit special consideration ;
and commend them to all members as they may
be individually interested.
If we may be pardoned for beginning near
home, we take pleasure in praising “Clinical
Interpretation of Blood Examinations” by
Robert A. Kilduffe, of Atlantic City ; publish-
ed by Lea and Febiger, price $6.50. Observa-
tion of his work inclines us to the belief that
everything done by Kilduffe is well done ; and
this book is no exception. He has covered the
subject in a comprehensive, all-inclusive, man-
ner and readers may safely rely upon his ad-
vice in the matter of interpreting laboratory
reports. As a book of reference, for the solv-
ing of “blood pictures”, it seems to us in-
valuable, and we extend to author and pub-
lisher thanks for providing such a complete,
accurate and reliable source of information.
Another neighbor and friend, Dr. Robert
N. Iveely, of Philadelphia, has turned litera-
teur and gives us “Paris and All the World
Besides” ; a biographic story of great interest.
Those physicians who, as students of medicine
in the last decade of the nineteenth century,
went “abroad to study in European clinics”
will appreciate Keely’s description of the
many nonmedical attractions that interfered
with prescribed curricula even though they
afforded opportunities for scientific investi-
gation. Many of his experiences were unique,
however, and very few men have had half so
many chances to witness or participate in un-
usual events. It seemed his fate to step from
one rare adventure into another, and if we
guess correctly he has not yet finished, for in
a personal chat within this month he announc-
ed the intention to “return to Paris” for a
visit this summer. If you want a few hours
of communion with a rare soul, and one who
has seen life with the eye of a physician as
well as an adventurous traveler, read Keely’s
book.
“The Baby’s First 2 Years” is the title of a
small book written by Dr. Richard M. Smith,
of Boston, published by the Houghton Mifflin
Company (price $1.75) for the purpose of
providing young or inexperienced mothers
with sage advice. It is particularly useful in
the matter of infant feeding and family
physicians could do worse than to recommend
this book to mothers who need an adviser
ready at hand.
“Easier Motherhood”, by Constance L.
Todd, gotten out by the John Day Company
($2), is a lay writer’s evaluation of Gwath-
mey’s obstetric analgesia by colonic injections,
and if it attains a wide circulation physicians
will doubtless soon have their patients pre-
scribing the technic to be followed in de-
livery. We doubt the propriety of public
education by this method. The publisher
states that: “One wholesome result of such an
informal demand (for Gwathmey’s techinc)
among women would be to make less popular
the operative interference with the normal
birth process which is now in vogue”, etc.
Operative interference is always wrong ; op-
erative intervention, even, may sometimes be
wrong, and we also feel that too many de-
liveries are being expedited by aid of forceps
or by cesarean section, but that situation can-
not be corrected by the patients. It is not
many years since some popular magazine
writers were insisting that all prospective
mothers should demand “twilight sleep”. To-
day we know that had the profession suc-
cumbed to that demand a goodly number of
women would have, in consequence, passed
into the next world. There is great need for
improvement in obstetric practice ; possibly
there is some need for closer attention to the
“humanities” on the part of some obstetri-
cians ; but no single method of inducing
analgesia or anesthesia has been discovered
that is applicable to all cases of child-birth,
and when a safe and reliable technic is dis-
covered its suitability for employment in
given instances must still be determined by
the doctor in attendance rather than by some
one in a distant literary office, or even by the
patient herself. We do advise physicians to
read this book, if only to ascertain what their
patients are being taught to expect or de-
mand.
“Suggestion for Contraceptive Practice”,
published by the Holland-Rantos Co., is a
booklet offered to physicians free of charge;
containing in condensed form much practical
information.
“Treatment of Diseases of Children”, by
434
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
Lust, published by J. B. Lippincott, price $8,
is a modern treatise that appears to lie well
worth its cost. The same publisher has re-
cently issued the following excellent books:
“Clinical Nutrition and Feeding in Infancy
and Childhood”, by Kugelmass ; “Burns”, by
Pack; “Tropical Medicine”, by Reed; each at
the price of $6. For up-to-date information
concerning these several subjects we know of
no better literary sources of supply.
“Treatment of Epilepsy”, by Talbot, pub-
lished by Macmillan, $4, is a timely and very
useful book. The general practitioner has not
been over-supplied with authentic text-books
upon the subject of epilepsy, and this work
should find a welcome niche in many office
libraries.
Equally practical in character is Carl
Beck’s “Crippled Hand and Arm”, for in
this machine age industrial accidents are fre-
quent and industrial surgery has few more
important problems than those concerned
with treatment of injuries to the hand. For
practical consideration of such injuries we
commend Beck’s book. In this connection, we
can also recommend Boehler-Lorenz’s “Treat-
ment of Fractures” which has been translated
from the German by Steinberg, of Portland,
Oregon, and sells for $5.
C. V. Mosby has sponsored a group of new
books that seem worthy of wide circulation :
“Infant Nutrition” ($5.50), by McKim Mar-
riott; “Physiology and Biochemistry in Mod-
ern Medicine” ($11), by J. J. R. Macleod;
and “Minor Surgery” ($10), by Hertzler and
Chesky. Again, industrial surgery has created
a demand for such books as the last men-
tioned above.
“The Challenge of Chronic Disease”, by
Boas and Michelson, and the “Clinical As-
pects of Venous Pressure” by Eyster; both
published by Mosby, $2.50 each, are quite ap-
propriate to the present demand for closer
study and better treatment of conditions that
affect us after 40 years of age and which tend
to curtail life. And, in association with these
books one may profitably read Gurd’s “In-
fection, Immunity and Inflammation”, and
Wyatt’s “Chronic Arthritis and Rheumatoid
Affections”, for most chronic affections have
their origin in some form of infection that
establishes a focal point from which to carry
on its devastating work.
If compelled to judge from manuscripts
submitted for publication we would say that
not so many physicians as should possess a
medical dictionary. So, to those in need of
such a desk companion we can say that Sted-
man’s, sent to us by the William Wood Com-
pany, will be found useful and valuable.
Finally, Johnson and Johnson, of New
Brunswick, offer to send any physician a copy
of a very serviceable book, 136 pages, on
“First Aid and Medical Service in Industry” ;
a helpful guide to those called upon to set up
infirmaries in shops and factories.
In Lighter Vein
Reversed Pimple
Definition of a dimple: A dimple is a lump in-
side out. — Carolina Buccaneer.
Wrong Label
“A spoonful of water contains 270,000 potential
horse-power”, says a scientist. That isn’t water.—
Life.
Losing Step with the Joneses
‘‘My dear, I can’t get a nurse for love nor money
— my baby-carriage is last year’s model!” — Passing
Show.
Latest Efficiency Wrinkle
Jaywalker — "So many people are struck by
autos while alighting from street-cars.”
Street-car Official — “Well, yes; but those people
have paid their fares. It’s this running over peo-
ple who are waiting to get on that makes me mad.”
— -Pathfinder.
Sorting 'Em Out
Soused Voice: “Hello, is this the city morgue?
Well, this is the Medical School. We want you to
come out and pick out the stiffs so the rest of us
can go home.” — Pitt Panther.
A new musical instrument, resembling a saxo-
phone, is said to be so simple in design that a
child can play it. It is a great pity. — The
Humorist.
Government chemists have found a new way to
make alcohol unfit to drink, but the bootleggers
really didn’t need a new way. — Publishers Syn-
dicate.
“What may be a certain cure for one person is
often utterly useless in the case of another”, says
a doctor. It is no good, for example, advising a
kleptomaniac to try to take things quietly in the
future. — The Humorist.
Customers That Come Back
We have served people in widely varying cir-
cumstances. We have conducted many very costly
funerals.
The fact that those we have served once return
again, and recommend us to their friends, is, we
feel, a high endorsement of the service we render,
regardless of cost. — Ad in a Downsville (N. Y.)
paper.
Biggest Boss
“Rufus, did you go to your lodge meeting last
night ?”
“Nah, suli. We dun have to pos’pone it.”
“How is that?”
“De Grand All-Powerful Invincible Most Su-
preme Unconquerable Potentate dun got beat up
by his wife.” — U. P. Magazine.
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
435
Preliminary Program
MEDICAL SOCIETY OF NEW JERSEY
The 165tli Annual Meeting, Berkeley- Cartaret
Hotel, Ashury-park
June 3, 4 and 5, 1931
ANNOUNCEMENTS
Credentials and Certificates
The Committee on Credentials will meet at the
hotel on Tuesday afternoon, June 2, and on Wed-
nesday morning, June 3. Its office will be open
constantly during the meeting.
The Constitution requires that all Fellows, Offi-
cers, Delegates, and Reporters shall register with
this committee.
Delegates must present to this committee a
certificate of election signed by the President and
Secretary of their respective component societies.
Without such certificate they cannot sit as mem-
bers of the House of Delegates.
Each member of the Nominating Committee
should present his certificate to the Secretary
before the opening of the afternoon session so
that the names of the Nominating Committee may
be announced, as indicated on the program. The
Nominating Committee will meet on Thursday,
June 4, at 5.30 p. m., in the committee room.
Papers and Reports
All papers read before the society or appearing
by title on the program, whether read or not,
thereby become the property of the society. The
author of each paper is required to give the Secre-
tary a legible copy of the same before reading.
The expense of alterations in a paper after it is
in type, and the cost of illustrations are borne by
the author. All manuscripts should be typewritten,
double-spaced, and on one side of the paper only.
Excepting orations, addresses of special guests,
and the Address of the President, the time to be
occupied in the actual reading of a paper is lim-
ited absolutely to 20 minutes. Those opening the
discussion are allowed 10 minutes each, others 5
minutes each.
Members desiring to present voluntary papers or
reports of cases should first have their papers ac-
cepted by the Committee on Scientific Work and
then apply to the Committee on Program for a
position.
Papers and reports not presented when called
for by the President cannot be presented at a
later time unless the regular order of business is
completed.
All members of component societies who are in
good standing are entitled to sit as associate mem-
bers and have the privilege of discussing papers
in the general session, but have no vote nor the
right to take part in the discussions of the House
of Delegates.
On arising to discuss a paper, the speaker will
please walk forward to platform and announce his
name and address clearly for the benefit of the
society. No member may speak a second time in
any discussion.
All sessions will be opened promptly at the hour
set, in order that the program may be carried out
as planned.
The Board of Trustees will meet at the Berke-
ley-Carteret Hotel, Tuesday, June 2, at 8 p. m.
Committees or Boards desiring meeting rooms
will please notify the Committee on Arrange-
ments, M. W. Reddan, Chairman, or W. D. Olm-
stead, Secretary.
The Berkeley-Carteret is operated on the Euro-
pean plan and the following special convention
rates are available to our members:
$5 per day, single room, bath or shower.
$8 per day, double room, twin beds, and bath or
shower.
All rooms are priced alike. Make hotel reserva-
tions direct.
The Berkeley-Carteret serves very splendid table
d’hote meals at the following prices:
Breakfast 60c to $1
Luncheon $1.50
Dinner $2
In addition to the above, a la carte service is
available at all times for those who prefer it.
Exhibits
Exhibits of instruments, books, pharmaceutic
preparations, x-ray apparatus, etc., will be shown
in the “Exhibit Hall’’ of the hotel and members
are urged to avail themselves of this opportunity
to examine the very latest improvements in these
various departments.
The degree of interest shown by the visitors in
these exhibits mathematically increases or de-
creases the revenue to the society. It’s up to you
to help.
HOUSE OF DELEGATES
Wednesday, June 3, 1931, 10.30 A. M.
Call to Order.
Report of Committee on Credentials.
Reading of Minutes of 1930 Meeting.
Report of Committee on Arrangements and Pro-
gram.
Report of Committee on Scientific Work.
Report of Committee on Publication.
Report of Secretary.
Report of Executive Secretary.
Report of Field Secretary.
Report of Welfare Committee.
Report of Board of Trustees.
Report of Judicial Council.
Report of Treasurer.
Report of Committee on Finance and Budget.
Report of Committee on Honorary Membership.
Report of Board of Medical Examiners.
Report of Committee on Post-Graduate Instruc-
tion.
Report of Committee on Hospitals and Medical
Education.
Report of Committee on Indemnity Insurance.
Report of Committee on Group Health and Acci-
dent Insurance.
Report of Delegates to the American Medical As-
sociation and to State Societies.
Afternoon Session
Wednesday, June 3, at 2.30 P. M.
(1) Unfinished Business.
(2) New Business.
SECTION OF SCHOOL PHYSICIANS
Wednesday, June 3, at 2.30 P. M.
Chairman: Allen G. Ireland, Director of Physical
and Health Education, State Department
of Public Instruction, Trenton.
436
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
(1) Foot Examinations in Public Schools
Donald B. Hull, Ridgewood
(2) Physician’s Part in Training of Teachers
Grace M. Kahrs, Jersey City (Physician
for the State Normal School at Jersey
City.)
(3) Facts in a Child Health Program of Com-
mon Interest to School and Community
Health Officials
I. W. Knight (District Health Officer, State
Department of Health.)
(4) Health in Education from the Point of View
of a School Administrator
Winton J. White, Englewood (Superin-
tendent of Schools.)
GENERAL SESSIONS
Scientific Program
Thursday, June 4, at 10 A. M.
(1) Surgical Aspects of Biliary Tract Disease
John B. Deaver, Philadelphia
Discussion opened by Max Danzis, Newark.
(2) Value of Duodenal Tube Drainage of the
Biliary System and Treatment of Various
Diseases and Disorders of the Liver
B. B. Vincent Lyon, Philadelphia
Discussion opened by Geo. IT. Lathrope, Newark.
Thursday, June 4, 2.30 P. M.
(1) Fusospirochetal Diseases of the Lung
(Illustrated with lantern slides)
F. J. Altschul, C. A. Pons, and
W. G. Herrman, Long Branch
Discussion opened by William P. Belk, Phila-
delphia.
(2) Cardiac Irregularities, their Clinical Recogni-
tion
Philip Marvel, Jr., Atlantic City
Discussion opened by Harvey M. Ewing, Newark.
<3) Silent Mitral Stenosis; its Detection and
Significance
J. Polevski, Newark
Discussion opened by A. E. Jaffin, Jersey City.
(4) Epitheliomas of the Skin; Differential Diag-
nosis and Treatment (Illustrated with lan-
tern slides)
Bart M. James, Newark
Discussion opened by H. J. F. Wallhauser,
Newark.
Friday, June 5, 10 A. M.
(1) Radiation of Bladder and Prostatic Carci-
nomas
Benjamin S. Barringer, New York City
Discussion opened by Stanley R. Woodruff,
Jersey City.
<2) New Views on Pathogenesis, Diagnosis and
Treatment of Ulcer and Cancer of the
Stomach, Cholelithiasis and Diseases of the
Digestive Organs in General
A. L. Soreci, New York City
Discussion opened by Joseph Samenfeld, Brook-
lyn.
(3) Findings of the Governor’s Conference on
Child Welfare and Protection.
Frank C. Johnson, New Brunswick
Discussion opened by Henry O. Reik, Atlantic
City.
(4) Role of the General Practitioner in Conserva-
tion of Vision
Elbert S. Sherman, Newark
Discussion opened by Elias J. Marsh, Paterson,
and Lewis H. Carris, Managing Director of
the National Society for the Prevention of
Blindness.
Special Order — 12 Noon
Presidential Address
George N. J. Sommer, Trenton
Friday, June 5, 2 P. M.
(1) Election of Officers (No other business).
Scientific Program at 2.30 P. M.
(2) Fees, Specialists, and Kindred Annoyances.
Elias J. Marsh, Paterson
Discussion opened by George H. Lathrope,
Newark, and Ephraim R. Mulford, Bur-
lington.
(3) An Etiologic Conception of the Disease
Entity
H. B. Logie, New York City
(4) The Conditioned Reflexes of the Cerebral
Cortex. (Pavlov’s epoch-making investi-
gations of the physiologic processes under-
lying the phenomena of thought, feeling
and conduct. Clinical problems of various
functional psychoneuroses his work eluci-
dates.)
William H. Hicks, Newark
(5) Manganese Poisoning
F. P. Wilbur, Franklin
Discussion opened by Christopher C. Beling,
Newark.
(6) The State’s Provision for 3 Types of Deaf
Children
Ethel Warfield, Trenton Junction,
Field Worker, New Jersey School
for the Deaf
SECTION OF OPHTHALMOLOGY, OTOLOGY
AND RH1NOLARYNGOLOGY
Chairman; Elbert S. Sherman, Newark
Thursday, June 4, 9.30 A. M.
(1) A Muscle-shortening Operation
Harry V. Hubbard, Plainfield
Discussion opened by George F. Sullivan, Ho-
boken.
(2) Clinical Management of Heterophoria
John H. Dunnington, New York City
(3) Combined Orthoptic and Operative Treat-
ment of Convergent Squint
Linn Emerson, East Orange
Thursday, June 4, at 2 P. M.
(1) Tumors in the Neighborhood of the Optic
Chiasm, with Special Reference to Eye
Symptoms
Thomas H. Johnson, New York City
Discussion opened by Wells P. Eagleton, Newark.
(2) Ocular Manifestations of Focal Infection
Samuel T. Hubbard, Hackensack
Discussion opened by Charles Zehnder, Newark.
(3) Non-traumatic Hemorrhage in the Vitreous
of Young People
Charles Franklin Adams, Trenton
Discussion opened by Wallace Pyle, Jersey City.
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
437
Friday, June 5, at 9.30 A. M.
(1) Some Cases of Facial Paralysis
E. P. Cardwell, Newark
Discussion opened by James A. Fisher, Asbury
Park.
(2) Important Factors in Surgery of Congenital
and Acquired Facial Deformities
Jacques W. Maliniak, Newark
Discussion opened by H. C. Barkhorn, Newark
and H. H. Kessler, Newark.
General Session Room
Special Order — 12 Noon
Presidential Address
George N. J. Sommer
Friday, June 5, at 2.30 P. M.
(1) Allergy as a Factor in the Etiology of Dis-
eases of the Nose and Paranasal Sinuses
Royce Paddock, Newark
(2) Accessory Nasal Sinus Infection in Children
G. W. Strickland, Roselle
(3) The Credulity of Rhinologists Anent the
Sinuses
Charles S. McGivern, Atlantic City
Discussion opened by Charles H. Schlichter,
Elizabeth, and Henry C. Barkhorn, Newark.
SECTION OF PEDIATRICS
Chairman: Elmer G. Wherry, Newark
Thursday, June 4, at 10 A. M.
(1) Tonsil Problem
Chester R. Brown, Kearny
Discussion opened by Henry C. Barkhorn, New-
ark.
(2) Symptomatology and Treatment of Thymus
Gland Conditions in Children
Paul Hosp, Newark
(3) Clinical Evaluation of a Palatable Concentrate
of Vitamins A and D
Joseph A. Marcus, Atlantic City
Thursday, June 4, at 2.30 P. M.
(1) Treatment of Heredosyphilis
F. J. McCauley, Newark
Discussion opened by Robert R. Sellers, Newark.
(2) Blood Transfusion as a Therapeutic Agent in
Pediatrics
Dewis W. Brown, Newark
Friday, June 5, at 10 A. M.
(1) Results Obtained in 40 Cases of Eczema on
a Milk-Free Diet
Julius Levy, Newark
(2) Importance of Differential Study of the White
Blood Cells, as Illustrated by Certain
Cases
Royce Paddock, Newark
(3) Influenzal Meningitis; Report of a Recovered
Case.
F. C. Johnson, New Brunswick
Special Order — 12 Noon
General Session Room
Presidential Address
George N. J. Sommer
WOMAN’S AUXILIARY TO THE MEDICAL
SOCIETY OF NEW JERSEY
FOURTH ANNUAL MEETING
Berkeley-Carteret Hotel, Asbury Park.
Wednesday, June 3
Golf Tournament for both women and men at
the Asbury Park Golf Club.
Wednesday, June 3, at 1 P. M.
Luncheon (subscription) and Executive Board
Meeting.
Wednesday Evening, June 3
Dutch Treat Supper Dance at Monterey Grill.
Thursday, June 4, at 9.30 A. M.
North Solarium
Call to Order Mrs. John Nevin, President
Prayer :
Ecclesiasticus 38: Honor the physician for
the need thou hast of him: for the most High
hath created him. For all healing is from God,
and he shall receive gifts of the king. The
skill of the physician shall lift up his head,
and in the sight of great men he shall be
praised.
Minutes of Last Meeting
Mrs. Dan S. Renner, Recording Secretary
Financial Statement
Mrs. Edward Clarke, Treasurer
Report of Standing Committees
Report of County Presidents
Speeches limited to 2 minutes
Appointment of Nominating Committee
Report of Committee on Revision of Constitution
New and Unfinished Business
Thursday, June 4, at 1 to 5 P. M.
Entertainment by Monmouth County Auxiliary
Boat trip on steamer leaving Long Branch at
Pleasure Bay dock about 1.30 and returning about
5 p. m. Trip will cover the Shrewsbury River out
past Atlantic Highlands, Twin Lights, and along
Sandy Hook into Lower New York Bay.
Buses will , leave Berkeley-Carteret Hotel about
1 o’clock and will return guests to hotel after the
trip.
Luncheon will be served at Fort Hancock.
Thursday Evening, June 4, at 7.30 P. M.
Crystal Room
Dinner Dance (Subscription).
Friday, June 5, at 9.30 A. M.
North Solarium
President’s Report Mrs. John Nevin, President
Report of Nominating Committee
Election of Officers
Unfinished Business
Installation of New Officers
Friday, June 5, at 1 P. M.
Auxiliary Luncheon (Subscription).
Guests of Honor:
Mrs. John O. McReynolds
438
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
Mrs. John Nevin
Mrs. H. Roy Van Ness
Dr. George N. .1. Sommer
Dr. John F. Hagerty
GENERAL ENTERTAINMENT
The following entertainment has been arranged
for by the Committee on Program and Arrange-
ments in cooperation with the Program Committee
of the Woman’s Auxiliary and a Special Com-
mittee appointed by the President of the Mon-
mouth County Medical Society.
Wednesday, June 3
Golf Tournament, all day, sponsored by the Mon-
mouth County Medical Society, at the Asbury Park
Golf Club, for men and women. All members of
the Medical Society of New Jersey, and all mem-
bers of the Woman’s Auxiliary to that Society,
are cordially invited to participate.
Prizes will be awarded for low gross and low net
scores — 18 holes — for both men and women play-
ers.
Also, there will be 4 prizes for winners and run-
ners-up in a Scotch 4-ball foursome for men.
Wednesday, June 3, at 8 P. M.
Dutch Treat Supper Dance at the popular Mon-
terey Grill; special music furnished by the
management.
Thursday, June 4, at 8 P. M.
Dinner Dance in the Ball Room of Berkeley-
Carteret Hotel. A splendid dance orchestra and
a hostess entertainer will be provided. Beautiful
prizes will be furnished by the Woman’s Auxiliary.
Reservations must be made at the registration
desk. Everyone is invited.
Friday, June 5
Golf for those who wish to play.
Special entertainment for the ladies for Friday
afternoon will be announced later.
Splendid meetings, teeming with interest, have
been arranged for and all members are urged to
attend.
Committee on Program and Arrangements.
Presessional Reports
ANNUAL MEETING
Presessional Report of the Welfare Committee
The newly appointed Welfare Committee held
its organization meeting at the Stacy-Trent Hotel,
Trenton, November 9, 1930. A. Haines Lippincott
was reelected chairman.
The report of the secretary, reviewing the work
of his office during the past summer, was present-
ed. Radio broadcasting of medical programs in
those sections where proper facilities exist was
thought to be worth while and it was decided to
continue the practice. The report covered briefly
the programs of the Field Secretary, Mrs. Taney-
hill, whose work has enlarged very much. The
demands on Mrs. Taneyhill’s time are constantly
increasing, due to the excellent cooperation of the
State Board of Education, whereby she has ar-
ranged contacts with all the school organizations
of the state.
Dr. Leo Haggerty, of Trenton, again volunteered
his valuable assistance in keeping us in touch
with proposed legislation that might need our con-
sideration, and the status of such bills. The pro-
fession and the people of New Jersey owe a great
debt to Dr. Haggerty for giving his valuable time
to this task.
There were many bills dumped into the hopper
this year that might be classed as medical legisla-
tion. After careful study of this proposed legisla-
tion by Dr. Reik, he concluded that there were
about 20 Bills that required consideration by the
Welfare Committee. These bills were carefully
considered by the Committee and a plan of ac-
tion decided upon.
It was decided that the Executive Secretary
should send a letter to every member of both
houses of the Legislature informing them of the
action of the Committee and the reasons for ap-
proval or disapproval in each instance.
Under the watchful eyes and convincing argu-
ments of Drs. Newcomb and Hargraves, in the
Assembly, and Dr. Cole in the Senate, supported
by the many friends of the profession who are
members of both Houses, at this writing we seem
to have checked or defeated all proposed legisla-
tion that had not the stamp of our approval.
We cannot be too optimistic, however, regard-
ing the future. We have learned our lesson from
past experience that there is not always safety
in quiescence.
The politicians this year had a diversion that
has taken up a great deal of their time and
thought. The great mass of bills that came out of
the report of the Abell Commission has possibly
drawn their attention from other matters in which
we as physicians are particularly interested.
The Abell Report dealt with many changes
and methods in state government, and we were to
a certain extent drawn into the whirl. We are
interested in the appointment of physicians to
Boards and Commissions where medical counsel
will benefit the state. While it has not been neces-
sary to call the Welfare Committee together but
3 times, the members responded to those calls
magnificently, with an enthusiasm and a willing-
ness to serve their profession and their state in
such manner that makes me proud of the honor
of having been chosen chairman of this group of
physicians.
A. Haines Lippincott, M.D.,
Chairman.
PRELIMINARY REPORT OF COMMITTEE ON
HEALTH & ACCIDENT AND AUTO-
MOBILE INSURANCE
Since our annual report to the House of Dele-
gates in June 1930, published in the Transactions
(Sept. Sup. 1930, p. 27) progress in the favorable
reception by members of our Health and Accident
policy, offered them through the society, has been
gratifying, and the settlements by the claim de-
partment have been extraordinarily liberal and,
without a single exception, satisfactory to claim-
ants.
Our keenness to make avail of any opportunity
to improve the contract, in coverage, or in pre-
mium rates, has resulted in successful negotiations
by which the term for indemnity for total disa-
bility from illness, is now increased from 4 to 6
weeks, and the requirement that the total disa-
bility must be “house-confining", is abolished. Prior
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
439
to this change, the committee often secured a
liberal adjustment for a member, in this matter
of house-confinement, beyond the terms of the
policy, but now we have it secured in the con-
tract.
We strenuously urge more consideration by our
members of the advantages of this policy on
Health and Accident insurance (which all doc-
tors should carry) for the reason that an in-
creased number of policy-holders will materially
help our negotiations for even more benefits.
The policies on automobile insurance are, as be-
fore, standard policies, offered our members at a
discount of 15 to 30%. These also have been well
received and are universally acceptable.
At the June convention an agent will be on
hand, with an exhibit, and ready to interview
members and answer inquiries.
Frank W. Pinneo, M.D.,
Chairman, for the Committee.
PRESESSION Al/ REPORT OF THE EDITOR
AND EXECUTIVE SECRETARY
Our society rules require publication of annual
reports at least one month prior to the annual
meeting. The period of time that must intervene
between the writing of this report (April 10), for
inclusion in the May Journal, and the end of our
fiscal year, compels us to present a message that
is preliminary and incomplete in character, and
to request the privilege of making alterations and
additions when preparing our final report for pre-
sentation to the House of Delegates in June. Such
tasks as have been completed can be reported in
full; those having 2 months yet to run will neces-
sarily have to be revised. We ask that this docu-
ment be considered as only a preliminary report.
(1) The Journal. If a president of the United
States may without injury to his native modesty
“point with pride” to the accomplishments of his
administration, surely a mere editor may be ex-
cused for directing attention to the things he has
done or attempted to do during his reign. While
serving in France with the American Expeditionary
Forces, we learned some of the principles of suc-
cessful warfare: (1) Over the top and dash for
the first objective! (2) Hold it! (3) Consolidate
your gains! (4) Prepare to carry along all you
have won and to jump off from the advance post at
the next zero hour for a new objective. Thus,
step by step, never relaxing hold upon any point
attained, and always reaching toward new attain-
ments, our efforts were crowned with success.
Pershing’s tactics were justified in war, and his
battle principles seem applicable to most pro-
gressive affairs in civil life. So, we have endeavor-
ed to apply them to journalism.
In 1924 the Journal of the Medical Society of
New Jersey was practically a replica of all other
state medical society journals; that is to say, it
regularly consisted of about 6 sections, or de-
partments, covering original articles, editorials, an
occasional special article or case report, county
society reports, obituaries and news items. The
total of reading matter for the year making 400
pages. In 1930 this Journal exceeded 1000 pages —
with an incidental increase of page size — embrac-
ing not 6 but 16 distinct sections or departments.
One at a time, commencing with Lighthouse Ob-
servations and running through Ethics, Esthetics,
Economics, Public Relations, Collateral Reading,
School Health, Public Health, Current Events, and
Woman’s Auxiliary, 10 new departments have been
introduced and by constantly adding and never
abandoning any established project, we have
reached the present admirable monthly edition, to
which we dare “point with pride”.
May we say that this degree of success has not
been attained without many hours of hard labor
— many hours more than the labor union re-
striction of an 8-hour working day — for our day
never shows less than 12 and seldom less than
16 hours, and, as we suppose must be true, the
editor of any periodical often wishes he might
know whether his clientele is 1 sufficiently well
pleased to justify all this expenditure of time and
energy.
Occasionally someone thinks to express general
approval or to praise a particular feature of the
journal; and on such days there is much joy in
the editorial office. Recently we had a “red let-
ter day”. While attending a Cumberland County
Society meeting one member voluntarily stated his
pleasure in reading this Journal and his pride in
it as the organ of his own state society. We
asked what he liked best about it, and we were
somewhat surprised by his response: “I like it
best because you are giving us such a variety of
interesting matter, all bearing on medicine or re-
lated to our professional lives, and yet much of
it being material that I never before saw nor ex-
pected to see in a medical journal.” It is scarcely
necessary to say that we were rendered very
happy, for he was the first to have mentioned dis-
covery of the goal toward which we have been
striving. It is the present purpose of the Journal
to record the scientific work of New Jersey physi-
cians, to supply them with information concerning
medical progress, to constitute itself a monthly
medium of post-graduate instruction, and to keep
its readers in touch with any and every thing that
can be serviceable to practitioners too busy to
read extensively in the field of general knowledge.
Returned home from that meeting we hastened
to compare your Journal with those of other states,
and we find that no other journal in this country,
state or national, offers anything comparable to
the wide variety of regular, monthly literary
pabulum of high grade that is contained in the
Journal of the Medical Society of New Jersey. A
few of the other state journals are “better dressed”
and make a more striking appearance because they
use a better quality of paper — especially import-
ant in the reproduction of illustrations — but in
most other respects we excel. Not only do we
surpass other publications in variety but we are
providing a much greater quantity of first class
medical reading. As repeatedly pointed out, we
consider many of our regular hospital staff and
county society reports fully equal to the average
of original articles published in any journal.
By way of comparing our own progress in re-
spect to quantity of scientific matter published,
our office secretary. Miss Mahoney, tabulated the
material in the bound volumes of 1924 and 1930.
The resulting figures showed 62 original articles in
1924, and 124 — exactly double — in 1930; 13 pages of
editorials in 1924, against 29 pages in 1930 ; 62 coun-
ty society reports in 1924, and 124 in 1930; 48 pages
of society and hospital reports in 1924, and 163
pages last year. And this does not take into con-
sideration the wealth of excellent original material
now annually contributed through the Tristate
Conference.
That you may have personally an opportunity
to make some comparisons, we are, following the
plan of last year, exhibiting in the adjoining room
the regular May issue of some 30 other state so-
ciety journals, and we invite criticism and sug-
gestions for further improvement of your own
440
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
magazine. The only recommendation the editor
has to offer at present is that as soon as the
financial situation permits, we may be instructed
to contract for a heavier grade of paper with a
good reproducing surface.
As stated before, we fully appreciate any word
of praise accorded our work but we reached the
pinnacle of happiness a few days ago, when the
monthly bulletin of the Middlesex County Society,
issued as a call for the April meeting, carried the
following announcement: “Hereafter, the Satur-
day Evening Post stays on the shelf; the Journal
comes first.” We thank the secretary of that so-
ciety.
(2) County Societies. During the fiscal year it
has been our privilege to visit all but 2 of the 21
county societies at least once, and to have made 2
visits to one county and 3 to another. It is a
pleasure to report that all of the component so-
cieties are active and most of them are func-
tioning in a praiseworthy manner. Following the
custom established by his immediate predecessors,
President Sommer has also attended regular meet-
ings of each and all (we believe) of the county
organizations, and we note with increasing satis-
faction, the good results of these presidential visits
and the visits made by the secretary of the state
society. Dr. Morrison. It is not solely that the
county members and the officers enjoy an ex-
change of pleasantries and sociability, but each
county unit feels that it is an important integral
part of the state and national organization. With
state officials present to be quizzed, the county
members have brought up for consideration some
of the problems that beset them and which vary
in different communities. Especially is this true
of economic problems, and this year it has be-
come manifest that the state society must help
to solve some of these problems, particularly those
relating to the Workmen’s Compensation Law,
and those growing out of industrial medicine as
it is developing in a variety of forms all over the
state. We respectfully suggest that the House of
Delegates shall take some action with reference
to these matters.
The Annual Conference of Secretaries and Re-
porters of County Medical Societies was held at
Trenton, November 5, 1930, and this proved to be
the most interesting session so far held. The pro-
ceedings were published in full in the December
Journal, pages 1000 to 1020. It was at that con-
ference that Dr. Walter F. Donaldson, Secretary
of the Pennsylvania Medical Society, spoke of the
advantages of Councilor District Meetings, and it
was out of the discussion following that of our
own secretaries, lead by the presiding officer, Dr.
George H. Lathrope, devised the plan for trying
such district meetings in this state. Our 5 dis-
tricts have all held meetings during the past few
months and while different plans were used, ac-
cording to the needs or the wishes of different
sections, or as experiments in some regions, we
believe that all proved successful; and we antici-
pate that the society will be asked to give official
endorsement to the general scheme.
It was at that conference, also, that Dr. Mor-
rison read his paper on the possible imminence of
state medicine; calling attention to its rapid
spread in foreign countries, its appearance in
Canada and its threatened advent here as evi-
denced by bills introduced into several state legis-
latures. Tbe conference, at the suggestion of Dr.
Fuhrmann, of Hunterdon County, adopted a reso-
lution to ask the state society at this annual
meeting to appoint a special committee to investi-
gate the working of so-called state medicine in
other states and countries, to collect all available
data, and to report the results at some future date.
In passing we desire to report that these con-
ferences have had a very beneficial effect upon
many of the county societies; one very noticeable
improvement showing in the character of pro-
grams now being issued.
(3) Woman's Auxiliary. This organization con-
tinues to thrive and we think has made definite
progress this year. The editor is lending such
aid as he may through the Journal and continues
to hope that an effective organization will ulti-
mately develop in every county.
Cooperating with the president of the state aux-
iliary, Mrs. Nevin, he has suggested, as a task for
the auxiliary, an effort to control some of the
obnoxious advertising being published in papers
and magazines and broadcast by radio. Mrs. Nevin
will probably present that question for considera-
tion by the auxiliary and by the society during
this meeting.
(4) Educational Work. Our program during the
year has been even more extensive than usual.
The field secretary will report personally upon
that part of the program entrusted to her. We
would only say here that she has, with the as-
sistance of the State Department of Education,
reached a very large number of desirable audiences
and that she has accomplished the fulfillment of a
huge program. That her work has been of su-
perior character is evidenced by the number of
commendatory letters received from each of the
counties visited by her, and by the almost uni-
versal request that she return again next year.
Our radio program has been carried this year
mainly by the county societies, and in our com-
plete report to the society in June we will furnish
a statement of the broadcastings from Atlantic
Bergen and Monmouth county societies.
(5) Public Relations. Among the larger move-
ments participated in this year were the Hoover
Child Welfare Conference in Washington and the
similar state conference called by Governor Lar-
son. We were invited to speak at the last men-
tioned gathering on the subject of cooperation,
and we endeavored to make clear to lay organiza-
tions the relationship of the medical profession to
such movements and the conditions upon which
we must insist if there is to be effective coopera-
tion in public health work.
Through an editorial in the February Journal
we took exception to some of the advertising re-
cently put out in printed form and by radio, which
in our opinion was insulting to the medical pro-
fession. The instance cited was not the only one
that might have been used. The radio threatens
to become more of a nuisance than a blessing un-
less a curb can be put on objectionable forms of
advertising. Wre feel that the profession should
object to, and should actively oppose, a number
of things now being done under the cloak of radio
entertainment. For instance, Amos and Andy are
being employed to veil an advertisement that has
passed from endorsement of a tooth paste into
actual prescribing of an alleged powerful anti-
septic for sore throat and colds in the head. We
suggest that the society give thought to this mat-
ter and consider what action may or should be
taken.
(6) Tristate Conference. The proceedings of
each successive conference have been published in
full in our Journal and we recommend continued
support of this project.
(7) Legislations State and national legislation
has occupied much of our time during tfie past
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
441
winter and spring but we are happy to report that
nothing detrimental to public health got past us.
More details will be supplied in our complete re-
port in June.
Respectfully submitted,
Henry O. Reik, M.D.,
Editor and Executive Secretary.
Lighthouse Observations
HEAD INJURIES OF MODERATE DEGREE
In a general review of 100 cases, including 50
In which ventricular studies were made, George
W. Swift (Northwest Med., 30:16, January 1931)
aays :
“One-third of all head injury cases seen in in-
dustrial surgery fall into a group of minor in-
juries. Perhaps there is some temporary loss of
consciousness, but the patients are strong indi-
viduals and to them it is more or less trivial. As
soon as the lacerations, if any, are healed, they
are ready to resume their work. With these we
have no further interest except to call attention
to the fact that a strong, robust individual who
receives a minor injury to his head, with no ac-
tual injury to the brain tissue, almost universally
returns to work at the earliest possible moment.
On another side we have that group of patients
who constitute perhaps another third of the sum
total, who receive a perfectly obvious total per-
manent disability, which is so recognized by the
attending physician and the Department of Labor
and Industries. This group of cases does not in-
terest us in the present discussion.
The remaining third is that group of patients
who, after a period of time, do not adjust them-
selves to their present condition. The factors in-
volved in thisi failure of readjustment are, of
course, first of all the injury itself. The more
severe the injury without total disability, the more
easy it is to observe physical findings which will
correspond to the subjective symptoms. This, one
might say, would constitute the upper margin of
disability in this particular group, while the true
malingerer, the man who feels that the state owes
him a living and uses a head injury merely as a
subterfuge, would be found at the other end of
the list. A great many patients are found be-
tween these 2 extremes and the factors which
might be noted as contributing somewhat to
their inability of readjustment are: Suggestion on
the part of the doctor, the relatives or other patients,
particularly those suffering from a similar injury,
perhaps of a more severe degree. An unstable or
nervous temperament almost universally leads to
failure of readjustment, even though the injury
may be very slight. Lastly, repeated injuries of
the same character to the same individual, each
causing a more lasting impression upon his men-
tal processes.
It is this group of cases which causes the great-
est difficulty both to the State Department of
Labor and Industries in arriving at a just com-
pensation or to insurance companies in estimating
the amount of compensable disability, and to the
physicians who are called upon to make these esti-
mations and evaluations.
With these facts in mind, a study has been made
of 100 cases falling in this last group, that is,
those who have suffered injuries to the head and
have not been able to readjust themselves to the
conditions found following the injuries. In this
are included 50 ventricular studies, used as a
check on the general physical examination. These
examinations were all made at the request of the
Department of Labor and Industries (Washing-
ton State) and wherever there was a reasonable
doubt that there was actually a physical lesion
which could be the cause of the failure of read-
justment, a ventricular study was done.
The average age of the patients was 42 and
the average time between the injury and our ex-
amination was 8 months. Only 12 of the 100 pa-
tients showed positive fractures in the roentgeno-
grams which were taken. We have, then, a com-
posite picture of a man approximately 42 years of
age, who 8 months prior to our examination had
suffered an injury to the head which had caused
subjective symptoms, such as severe headache,
dizziness, general weakness, disturbances in hear-
ing and vision, loss of memory and localized pain,
who presented practically no neurologic findings
except increased reflexes and passive congestion
of the vessels of the retina. In only 12% of cases
did roentgenograms show fracture of the skull,
yet this average individual has been unable to ad-
just himself to his surroundings.
In tabulation of the roentgenograms, showing
displacement of the ventricles, we find bilateral
displacement in 2 cases, dilatation of the ventricles
in 4 and compression of the ventricles in 4. In
13 cases, or 26%, air showed over the cortex.
In glancing at the subjective symptoms, we
find disturbance of hearing, disturbance of vision,
localized pain and general weakness in about the
same percentage of cases as we find distribution
of air over the cortex. Practically all patients
showing air over the cortex complained of these
symptoms. There does not seem to be any rela-
tion between the degree of headache and dizziness
and the ventricular findings of air over the cor-
tex or disturbance in the ventricular system. As
practically all of the patients on whom a ventricu-
lar study was made complained of both headache
and dizziness and only 25% showed cortical air, it
is fair to assume that only 1 in 4 actually were
suffering from severe headache and dizziness.
This brings us, then, to discussion of the rela-
tive value of the history, physical examination and
ventricular study in these cases. Obviously, the
history, while important, if combined with the pa-
tient’s statement as to symptoms, is of value in
only 25% of the cases. Nor does the physical
examination yield much more information. The
ventricular study is more accurate and gives posi-
tive tradings. Particularly is this true in the case
of a general edema and it also suggests the treat-
ment which is of greatest benefit to these patients,
namely, dehydration followed by limitation of fluid
intake.
It is not going to be possible to secure ventric-
ular studies on all questionable cases, nor will it
be possible to estimate exactly the degree of com-
pensable injury, but it will be possible for the
medical profession to give better treatment at the
very beginning of the injury. This, no doubt, will
do away with many actual disabilities. It will not
help in those cases in which there is a tear of the
arachnoid with accumulation of cerebrospinal fluid
about the cortex, as first noted by Naffziger.
Secondly, we must look forward to the time when
all those engaged in active industry shall have
to submit to a physical examination and have
noted the actual condition present at the time of
securing the position. An injury subsequent to
this examination can be checked by the previous
physical condition of the patient. Lastly, there
must be in industry, just as there is in our colleges
today and in the business world, a reclassification
442
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
from the standpoint of temperament and adapta-
bility. Men who are constitutionally psychopathic
to begin with cannot be permitted to enter hazard-
ous occupations, where the slightest injury will
bring about claims for complete and total disa-
bility.
Public Relations
GOVERNOR LOOKS AT CHIROPRACTIC
(From Jour. A. M. A., 96:1148, April 4, 1931.)
Governor Buck, of Delaware, has returned to the
legislature, without his approval, a bill to create a
board of chiropractic examiners and to regulate the
practice of chiropractic. His summarization of
the reasons for his veto is so clear and terse that
it should be read by the legislators and governors
of every state that is threatened or already afflicted
with this cult. His statement follows:
The purpose of the act, as I understand it, is to
legalize the practice of chiropractic in this state.
Practitioners of this cult are not recognized now.
Do they profess to be doctors in the same sense
of the term as is commonly understood to apply
to men and women of the medical profession? In-
sofar as I am able to determine, there is not a
recognized medical school in the country that in-
cludes in its curriculum a course in chiropractic.
This fact in itself seems singularly significant.
Even to the lay mind the idea that all disease of
whatever character is due to spinal displacements
of a mild sort, and that cures of such ailments as
tuberculosis, small-pox, diphtheria, scarlet fever
and others can be effected by manipulation and
fingering of the spine is preposterous.
Before returning this bill to you I have satisfied
myself that the training and education a chiro-
practor, or a drugless healer, needs to practice his
art does not fit him properly to advisedly treat the
sick, inasmuch as he is not qualified to diagnose
ailment nor recognize communicable diseases and
to take measures to control them. He is there-
fore an opponent to the department of health.
Wherefore, it seems to me it would be incon-
sistent for the legislature to appropriate, as it will
do, money for the state board of health, which
board is trying to eradicate communicable diseases,
and at the same time legalize the practice of a
cult which does not believe in the germ theory of
disease but does teach and believe that such dis-
eases as scarlet fever, etc., are due to a distracted
vertebra and the method to prevent and cure such
disease is to see that everybody has a normal spine.
(Italics supplied by Editor.)
NEWARK TOPS CLASS IN HEALTH RATING
V. S. Chamber Also Cites Three of Oranges
For Conservation Work
(Washington Bureau. Newark News)
Newark last year was the leading city of its
class in health conservation in the United States.
The city received first rating today for cities
between 250,000 and 500,000 population in the na-
tional health conservation contest conducted by
the Chamber of Commerce of the United States
with cooperation of the American Public Health
Association.
East Orange, West Orange and South Orange
were among 30 “honor” cities named by the judges
in addition to 6 class winners. In last year’s con-
test, East Orange won first place among cities of
50,000 to 100,000 population.
The 5 winners, in addition to Newark, among
149 entrants were: Above 500,000, Detroit; 100,000
to 250,000, New Haven; 50,000 to 100,000, Racine,
Wis.; 20,000 to 50,000, Alhambra, Cal., and less
than 20,000, Chestertown, Md.
Reports from entrants were submitted several
months ago and analyzed by a grading committee.
Personal inspection by the committee was made
of winning cities before awards were announced.
Contest points included water supply, sewage
disposal, protection of milk supply, preventive
measures, medical conferences and clinics, pro-
grams for prevention and early care, life loss sta-
tistics for preventable diseases and support for
local health work by official and unofficial agencies.
Awards will be presented April 28 to May 1 at
the annual meeting of the national chamber in
Atlantic City.
REPORT TO THE COMMISSIONER OF LABOR
BY THE WORKMEN’S COMPENSATION
ADVISORY COMMISSION
Newark, N. J.,
March 11, 1931.
Honorable Charles R. Blunt,
Commissioner of Labor,
Trenton, N. J.
Dear Sir :
The undersigned, constituting an Advisory Com-
mittee appointed by you to examine into the op-
eration of the Workmen’s Compensation Bureau of
the Department of Labor and the administration
of the laws relating to the same, beg to report as
follows:
The Workmen’s Compensation Act, which was
originally enacted in 1911, was designed to secure
to injured workmen or their dependents, definite
amounts of compensation for injuries suffered and
pecuniary loss sustained, irrespective of the ques-
tion of fault and negligence on either part of the
employee or employer, and it was intended that
the statute should be liberally construed in order
that the economic loss resulting from injury to the
employee should be reduced as much as possible.
Amendments to the law have been made from
time to time, increasing the amount of compensa-
tion awarded for the term for which the stated
compensation should apply, and in other respects
as experience demonstrated defects and weak-
nesses in the original Act.
In order to obtain as wide and as thorough in-
vestigation as possible you have appointed as
members of the Advisory Commission representa-
tives of labor, industry, law, medicine and insur-
ance, and in the conduct of our investigation we
have extended invitations to various groups repre-
senting these various interests, and have been
favored with their views on a number of questions
relating to the Act itself, and to the operation of
the Bureau.
We find at the outset that, while the cases re-
ported to the Bureau during the first full year of its
operation numbered 11,922, during the year 1930
the total number of cases had increased to 28,269.
These figures would seemingly indicate the neces-
sity for enlarging the administrative staff, as well
as the equipment and facilities necessary to proper
administration of the law, but we find that there
has been no increase in personnel, equipment or
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
443
other facilities proportionate to the increase of
the business of the bureau, and this fact has been
the cause of a number of criticisms which have
been addressed to us. The old headquarters of the
Bureau at No. 9 Franklin Street, in the City of
Newark, were notoriously inadequate and removal
of the department to the new headquarters in the
Industrial Building- has eliminated one of the chief
causes of complaint to which our attention has
been called.
A majority of the various interests that have
given us their views with reference to the opera-
tion of the Bureau, are of the opinion that the
Bureau has not a sufficient personnel in the way
of referees and examining physicians, in order to
examine and pass upon cases in full fairness to
the injured employee, the employer, or the insur-
ance carrier. The evidence before us indicates
that in some cases, owing to the pressure of busi-
ness or the limited time available for the work
of the State Physicians, the physical examina-
tions are not as thorough as they should be. A
criticism has also been made of the practice of
notifying claimants, employers, insurance carriers
and other interests in a large number of cases to
appear at the Bureau at a stated hour in the
morning, and that by reason of the large num-
ber of cases set down for a particular tim,e, and
the length of time necessary to get through the
list, the time of the interested parties is largely
wasted in waiting to be heard. This seems to us
to result partly from the lack of sufficient per-
sonnel, as above indicated, as well as from the
practice of assigning more (too many) cases for
hearing at a stated hour in the morning instead
of being scheduled for different hours during the
day. It seems to be the consensus of opinion, and
we so find and report, that at least 2 additional
referees should be appointed and that the medical
staff should be enlarged correspondingly.
As to the medical staff, we have had additional
criticisms to the effect that certain physicians em-
ployed by the Rehabilitation Clinic, have also at
various times become interested in compensation
cases either on behalf of an injured workman or
in behalf of an employer or insurance carrier. It
is our belief that the physicians employed by the
state should be prohibited from engaging in such
practice. It has been suggested that the work
•of the Bureau would be expedited and rendered
more effective by the employment of a physician
or physicians on a full-time basis, at an adequate
salary, and we have been advised that a com-
petent physician can be obtained, whose full time
could be given to the examination of cases coming
before the Bureau, at an adequate salary. We do
not doubt that if such a physician were employed
and would attend at the Bureau every weekday for
the purpose of making examinations, and that
such physician be precluded from engaging in
practice on behalf of any injured workman, em-
ployer or insurance company, that the work of
the Bureau and its results would be materially
enhanced. The Commissioner of Labor should
also be authorized to engage as many as 3 inde-
pendent physicians to make examinations and ad-
vise the Deputy Commissioners of any important
case where it appears to the Deputy Commission-
ers that the testimony of the physicians obtained
by the parties is in irreconcilable conflict.
There seems to be also a very strong sentiment
among the majority having contact with the
Workmen’s Compensation Bureau, that in no case
should a case be set down for a formal hearing
“until the matter has been examined into at an in-
Tormal hearing, and a recommendation made there-
in by the Referee or Deputy Commissioner, so that
the parties involved may have the opportunity of
speedily settling or adjusting these cases if they
so desire. It has been urged upon our attention
that there have been many cases which could be
informally adjusted by a Referee without delay
and to the entire satisfacion of all parties con-
cerned, but that owing to the intervention of cer-
tain lawyers and doctors whose chief interests
seem to be in obtaining the allowance of fees,
these cases are not permitted to be informally ad-
judicated by a referee but are set down for a
formal trial. This practice necessarily suspends
and delays the payment of compensation when it
is most needed, and in the long run seems to work
more to the benefit of the doctors and lawyers who
become interested in cases rather than to the
claimants themselves.
We, therefore, believe it would be in public in-
terest that in these cases the claimant should at
the earliest possible date report to the Bureau for
a physical examination, and that at such time
claimant should be examined by a Referee as to
the time and place and circumstances of the acci-
dent and extent of the injury, and the present
condition of the claimant stated, and duly record-
ed with the recommendations of the Referee, and
a docket, file or other record kept for that pur-
pose.
It has also been suggested and we recommend
that, if at places like Newark, Jersey City, Pater-
son, Camden or wherever a large amount of work
falls on the attending referee or examining doc-
tor, he be provided with a stenographer to make
a record of the facts elicited instead of the long-
hand method now in use, and that such record
be made a permanent file, and that such file
should in all cases be made part of the cases
to be submitted to the Deputy Commissioner
on final hearing. The procedure in practice in
Jersey City appeals to us as that which should be
adopted generally.
We have had considerable evidence indicating
that the practice before the Bureau on the part
of certain attorneys and physicians is becoming
commercialized; that there is a certain amount
of “ambulance chasing” on the part of the doc-
tors, lawyers and runners, and that this practice
is carried on in the quarters of the Department of
Labor, and this charge has been made with re-
spect to cases which, although being satisfactorily
handled by the referees, might be made the oc-
casion of obtaining professional fees by throwing
the matter into a formal hearing.
Another matter with reference to which we have
had considerable criticism, is- the practice of State
physicians recommending to the Referee and
Deputy Commissioner the allowance of some ar-
bitrary percentage for assumed permanent dis-
ability, in cases where there has been or is indi-
cated a complete recovery from a temporary dis-
ability. Doubtless there are cases of fracture fol-
lowed by a complete union which may cause fu-
ture recurring pain or disability, but we do not
believe that the letter or spirit of the Workmen’s
Compensation Act justifies general allowance of
permanent disability percentage where the injury
is of a temporary nature.
Much criticism has also been expressed before
us in the matter of making allowances for at-
torneys fees and medical fees. The statute au-
thorizes in contested cases the allowance of at-
torney fees not exceeding 20% of the amount of
the judgment except in cases where compensation
has already been paid, in which event the at-
torney’s fee is based upon the excess compensation
444
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
awarded on the final hearing. The criticism in
this connection is that some of the deputy com-
missioners have in the past frequently awarded
the full 20% of the judgment or of the excess, as
the case may be, without recognizing that the
amount suggested by the statute is a maximum
amount and not an arbitrary percentage to be ap-
plied in all cases. The same criticism is directed
to the allowance for medical fees. The statute
directs an allowance of a maximum of $50 to any
one physician, not exceeding $150 in any one case,
and it has been stated that, as to these allowances
also, the practice of the deputy commissioners is
to allow $50 to each physician, notwithstanding
that the same physician may appear in 3 or 4
cases before the same deputy commissioner on
the same day. We believe that if the design and
purpose of the law were kept in mind by the
deputy commissioners, and the legal and medical
fees based on the actual work done, it would dis-
courage to a great extent the apparently growing
practice of commercializing compensation cases
by doctors and lawyers.
Requests have been made, in which we concur,
that the rules of the Bureau be amended to provide
for 5 days’ notice to both parties of the dates of
informal hearings, and that the time for filing an
answer to a formal petition be extended to 20
days instead of 10 days after service of the pe-
tition or bill of particulars.
It has been called to otir attention that fre-
quently a case is repeatedly set down for hearing,
and the petitioner does not appear or notify the
Bureau in advance of the fact that he will not
appear. This may be due partly to the fact that
the petitioner’s address does not properly appear
in the records or that the petitioner may have
moved from the the address given at the time of
the injury, and it is suggested, and we concur in
the recommendation, that where a case has been
set down for hearing, and ample notice is given
to the petitioner, and the petitioner does not ap-
pear, such case should not be again assigned for
hearing except on the request of the petitioner.
We also concur in the suggestion that in every
case either the employer or insurance carrier be
authorized to accept and endorse acknowledgment
of service of petitions, as this is a common method
used in civil suits of law.
We have given consideration to numerous sug-
gested amendments to the Act, many of which
seem to be desirable, particularly the following:
Repeal the provision relating to penalty for
failure to file accident reports, and extend the
period of limitation in which petitions may be
filed to 2 years. AJso to extend the time for
filing a petition by a widow or other dependents
until 1 year after the date of death of the in-
jured.
That all nonresident employers engaged in work
and hiring labor within the state of New Jersey
should be required to provide security for any
liability they may incur in New Jersey under our
Workmen’s Compensation Act, or, that the ser-
vice of process upon the Secretary of State be
made a valid method of service in all cases where
nonresident employers cannot otherwise be served.
To abolish the appeal to the Common Pleas
Court and provide for review by writ of certiorari
in the Supreme Court.
Amend the hernia section of the Act so as to
provide for a 48 hour notice whenever an accident
occurs on a day preceding a Sunday or legal holi-
day.
Substitute for Section 23F a new Act providing
that the employer or insurance carrier may in-
stitute an action against third persons in the event
that the injured employee refuses or neglects to
institute such action within a limited time.
While it might be desirable to make a number
of other changes in the laws, we do not believe
that further amendments of the statutes should
be attempted. We urgently recommend, however,
that the entire body of the Workmen’s Compen-
sation Laws should be entirely revised. The act
of 1911 has been amended 15 times, and the sup-
plement of 1918 has been amended 7 times, and
other supplementary acts have been passed, so
that the law as a whole is now in a state of corn-
fusion, and in many instances of inconsistency.
In our judgment, it is impossible to adequately
amend the law so as to provide an harmonious,
understandable and workable code covering the
matter of workmen’s compensation. The whole
matter should be revised, modified and clarified
to afford a better understanding and proper ad-
ministration of the law.
In conclusion, we would like to take the oppor-
tunity to express our commendation to the Com-
missioner of Labor, as well as to the personnel of
the Bureau, for the satisfactory manner in which
most of its affairs are being conducted. Notwith-
standing the criticisms offered in the foregoing
pages, we find that everyone in the Bureau is
making a conscientious and determined effort to
better the general efficiency. As a matter of fact,
noticeable improvement has been made, in our
opinion, during the past 8 months while the Com-
mission was functioning. We wish to express our
thanks officially, also, for the cooperation of the
Deputy Commissioners and Referees, whose com-
ments and explanations have been very helpful.
Respectfully submitted,
Thomas B. Eames
Maximilian M. Stallman
W. S. Landes
J. B. Morrison, M.D.
A. Duncan Reid.
School Health Department
. NOTES FROM LOS ANGELES
Allen G. Ireland, M.D.,
Director of Physical and Health Education, State
Department of Public Instruction, Trenton.
The Los Angeles school system has won deserved
fame for its health and physical education pro-
gram. From its last annual report the following
excerpts have been taken.
Importance of exclusion. “It has been discovered
by experience that it is much better to exclude a
number of pupils for 1 day or 2 with minor ail-
ments, than to allow 1 child with suspicious symp-
toms to attend school until a positive diagnosis of
communicable disease can be made. This is es-
pecially important in view of the fact that measles
and scarlet fever, for instance, are more con-
tagious for several days before the diagnosis is
usually made. The exclusion of every child from
school who suffers from an acute cold has re-
duced the number of cases of influenza, pneumonia,
measles, whooping-cough, mumps, meningitis,
diphtheria, scarlet fever, septic sore throat, and
bronchitis. Most of our communicable diseases be-
gin with symptoms simulating the common cold.
By control of acute colds among school children,
we have gone a long way toward aborting most
of our epidemics. These symptoms are very easily
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
445
detected by the teachers, and they have been in-
structed to exclude all such children.”
Keeping schools open. ‘‘It has been agreed
among health officers that a properly inspected
school room is the safest place for a child during
the outbreak of an epidemic. By school inspection,
the children acutely infected are excluded and
thus separated from the other children, at the
same time reducing the number of contacts.”
The School Physician
The following is an excerpt from an article by
Dr. John L. Goflin in the March, 1930, issue of
School Life. Dr. Goflin is Assistant Health Super-
visor of the Los Angeles Schools.
“This situation points unmistakably to the ne-
cessity of special training for school physicians,
both medically and educationally. Authorities in
school health work are now pretty generally
agreed that the prospective school physician needs
special instruction in pediatrics, orthopedics, sani-
tation, contagious-disease control, and in the prin-
ciples of health education and the organization
and administration of health education. There is
also a growing feeling that the school physician
should be a full-time worker, who enters school
health work as a specialty with the idea of ad-
vancing himself steadily and making it his life
work. If we are to make school health work a
dignified and useful profession, we must provide
professional and economic incentives. Profession-
ally, the school physician must be assured a steady
and progressive growth; economically, he must
be rewarded commensurately with his knowledge
and skill. I can see no valid reason why the
specialty of school health can not be made as
attractive professionally as any other specialty in
medicine. As at present organized, a very large
amount of routine work is required and too little
time is allowed for research. There is very little
opportunity for keeping children under close ob-
servation for long periods. There is practically
no opportuntiy for treatment in the medical
sense.”
Minimum Standard
This resolution was adopted by the American
Public Health Association and the American As-
sociation of School Physicians.
Whereas school physicians as a class have not
heretofore been adequately prepared for the work
which our complex educational systems now de-
mand, and
Whereas school physicians have not heretofore
been paid a salary sufficient to justify this ad-
ditional training, and enable them to devote their
full time and best efforts to this work, and
Whereas it has become necessary to take
definite steps to improve this situation, therefore,
be it
Resolved, That the American Public Health As-
sociation and the American Association of School
Physicians, in convention assembled, do recom-
mend consideration of, and action upon, by the
various states, the following minimum require-
ments for new school physician applicants:
(1) Graduation from an acceptable medical
school, 1 year of acceptable internship, and a
license to practice medicine in the state.
(2) Six semester hours of graduate training in
medical subjects relating to school health work.
(3) Six semester hours in a school of education
of work embodying the principles of health edu-
cation, and the organization and administration of
same.
(4) This 12 hours of graduate work must be
completed within 3 years after certification by the
State Board of Education.
And that they further recommend:
(1) The establishment of a salary rating equiva-
lent to that now granted the high school principals
in their respective localities.
(2) That this salary be subject to automatic in-
crease according to length of service.
(3) And that it be subject, also, to an increase
commensurate with educational merit and pro-
gressive professional development.
Communications
ONE REASON WHY PATENT MEDICINE
VENDORS THRIVE
(Parody upon a Hospital Staff Meeting, sub-
mitted by one of cur members who vouches for
the truth of the essentials and declares this ac-
tually happened in one of New Jersey’s large
cities.)
A type-written card came to Dr. Deutsch’s office:
Consultation — meeting at the General Hospital on
Tuesday, February 17, at 9 p. m. Subject: Obscure
conditions of the liver.
These consultation-meetings were held once a
month in accordance with the regulations of the
College of Surgeons.
Primarily, they were held to discuss cases treated
in the hospital in which a fatal ending had not
been averted.
But even the doctors do not like to hear of
death more than they have to — so, in our hospital
the Committee on Program was obliging and tried
to offer something of interest to nearly everybody.
The evening of the seventeenth of February was
given over by the chairman to a doctor who pre-
sented 4 patients, all males, whom he, to the best
of his ability, had cared for until such time as
surgical intervention seemed the only way out.
In his zeal to make the evening attractive he had
asked all 4 men whose cases were to be discussed
to be present at 9 o'clock to show that they were
very much alive.
The doctor exhibiting these patients was of the
antediluvian type; he still sported the mustache
and goatee so popular a quarter of a century ago,
and it was only recently that he had changed from
an open-air horse-drawn vehicle to a closed
automobile — a Ford. He still prescribed Lloyd’s
Specifics, Echinacea, and other - remedies of which
he did not know the composition; but he could tell
stories entertainingly, and all grandmothers liked
him because he never “queered” them in their
use of poultices or home-remedies.
He had easy-going manners and a laugh resem-
bling the exuberance of a goat.
He was a strictly medical man, not a surgeon.
Dr. Pushemover, whom he had asked to operate
on his patients, was also present.
Dr. Goatee opened the meeting: “Gentlemen, we
have here present with us 4 patients who have
been operated on in this hospital. The first, Mr.
Hiram Bunk, was here — let me see — was it in 1928
— that’s right?” “Yes”, said Mr. Bunk, “I was
operated on June 21, 1928.”
“And are you entirely well”, asked the doctor.
“I was never better in my life”, answered Mr.
Bunk.
“Gentlemen”, spoke the goateed doctor, “to-night
Mr. Bunk is celebrating the twenty-fifth annivers-
ary of his wedding to one wife and I think, on a
446
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
day like this, we ought to excuse him.” Exit Mr.
Bunk.
The second victim of surgery was then present-
ed. He, too, stated that he was well — and so did
the third and fourth patients. They were excused
and allowed to depart.
Now came the interesting part of the evening —
discussion of the state of the livers of these pa-
tients who had really never been made acquainted
with what ailed them. Dr. Goatee read all the data
from the charts — it took him a long time to search
through the records to find what he wanted but
at last, with infinite patience, he was able to tell
the audience what, in his opinion, each patient
was not suffering from.
One of the men, Mr. Liverwell, had been sick
quite some time with fever and jaundice; there
was no end to the fever and nothwithstanding the
quinin and the Lloyd’s Specific’s given to him,
the man did not improve.
Dr. Goatee decided to call a consultant. This
eminent doctor, living in New York City, would
condescend to come to our town for $500. That
was too much. Another consultant telephoned to
say he would come out for $100. His fee was
agreed to.
After examination, this New York specialist
said: “Do you know what you have there? An
abscess of the liver. Yrou’ll have to take him to
the operating room.”
“If the man is willing, will you operate on him?”
asked Dr. Goatee.
“Certainly”, replied the consultant, “but that will
be $150 extra.”
The man was willing. The consultant opened the
abdomen, saw nothing abnormal with the liver,
and proceeded to pierce that organ with long
needles in direction perpendicular, oblique and
tranverse, but no pus was found. The operator
finally gave it up as a bad job and closed the ab-
domen. The patient’s temperature after operation
remained the same as before — around 101° in the
morning and 103° in the afternoon — but after some
4 weeks or more the temperature dropped to nor-
mal and gradually the man got well.
Mr. Bunk’s case excited the most interest. After
nearly a year’s ailment, with lack of appetite and
a slight pain over the liver region, he developed
a fever which arose sometimes to 104°. Dr. Goatee,
who saw that the man was jaundiced, thought that
he was possibly suffering from gall-stones, and
with this idea in mind he called in Dr. Pushem-
over who agreed with him and suggested an op-
eration.
At operation the gall-bladder was opened but
no stones were found. The liver was enlarged
about 2 finger-breadths; there was no tumor, but
some peculiar spots, white, and of the size of a
pin-head, were present on the liver’s surface.
Dr. Pushemover, who was a protege of the Hos-
pital’s Board of Governors, perhaps wasn’t quite
as experienced in dealing with livers as he should
have been. He had never seen a liver with spots
like those of his patient. He therefore called them
cancer — which was a risky thing to do because
time would ultimately prove him right or wrong.
Anyway, it was then declared to be cancer and
the patient was sewed up and put back to bed.
The fever continued as before but, strange to
say, Mr. Bunk recovered in about 8 weeks notwith-
standing the operation. His disease condition had
been called cancer, and the family had been told.
A drowning man catches at straws, and this pa-
tient, made aware of his condition, wrote to Mus-
catine, Iowa, for information regarding a certain
Cancer Specialist.
The most interesting part of the meeting was
now to begin. Dr. Goatee had presented his cases
— all 4 patients had come to operation but the op-
erations had not cured them — all 4 had continued
to have high temperatures for weeks until at last
nature, or their own resistance powers, had put
them back on their feet.
The Chairman of the meeting announced that
the report was open for discussion.
A surgeon of the staff asked whether a piece
of liver tissue had been removed for examination,
from the man who was supposed to have had can-
cer.
“No”, answered Dr. Pushemover.
“Why, then, was the condition diagnosed as can-
cer?”— asked the Staff Surgeon.
“We supposed that those white spots on the sur-
face of the liver were metastases from cancer in
some other parts, but evidently we were wrong.”
Another doctor spoke up and said that he
could not understand how a diagnosis of cancer
could have been made if the temperature curve
had been taken into consideration — he had never
seen a cancer of the liver exhibit that particular
curve, which looked more like a septic temperature
record than anything else.
Another man arose and said: “I am very glad
that this case of supposed cancer has come up for
discussion. I have often wondered if this man
Bunk, whom everybody in this town seems to
know, really had a tumor or a cancer at the time
of his operation. The facts of the case have now
come to light. Whenever I see a case of cancer,
in my practice, someone invariably mentions
Hiram Bunk who, as the whole town is told, ‘has
been cured of cancer by taking patent medicine
after the doctors who had operated on him, had
given him up to die’. I am, and always have been,
thoroughly disgusted when hearing the praises of
this patent medicine, knowing well enough that
no such medicine has ever yet cured real
cancer. I listen to the talk of superstitious
gullible people, but it is a conundrum to me how
a certain doctor on the staff of this hospital, and
who is also a member of the American Medical
Association, can be so naive as to advocate use
of that patent-medicine because it is said to have
cured Mr. Bunk. What is more, there is also a
nurse in this hospital who recommends this medi-
cine to all victims within her reach.
And now, I will read to you, from the Cancer
Specific booklet, Mr. Bunk’s testimonal.
‘To whom it may concern:
I was operated upon on June 21, 1928, for a
gall-bladder condition but the surgeon found an
advanced cancer of the liver. After the shock of
the operation had passed, I started to take your
Cancer Specific and have continued it right along.
I now feel better than I have for years. All signs
and symptoms of the condition seem to have
passed away. Hardly a week goes by but what
I have 2 or 3 inquiries about your medicine and
I heartily recommend it to all.
Y'ours very truly,
Hiram Bunk.’ ”
Dr. Pushemover made himself as small as pos-
sible. He -was evidently embarrassed. Bunk’s can-
cer medicine sold like hot cakes in the town,
because of the living testimonial walking the
streets “after 2 able doctors had condemned him
to die of cancer”.
Another man got up and said: “Not only does
a doctor recommend this medicine but we have in
our midst a minister of the gospel who thinks he
is very close to our heavenly father — and he, too,.
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
447
‘knows that Bunk has been cured by the Cancer
Specific’ and he tells all the members of his con-
gregation that it is foolish to call in a doctor in
any case of cancer.”
On motion, the meeting was adjourned and the
refreshments brought in.
The refreshments consisted of coffee, diminutive
sandwiches and heavy slices of ice-cream with
cream-puffs, lady-fingers and chocolate-coated
sweet things.
“How can you sleep?” asked the President of
the Staff of Dr. Deutsch, “after a cup of strong
coffee?”
“I am a Dutchman”, said Dr. Deutsch, “I am a
drinker, but not an eater — for instance, I don’t
eat ice-cream — I don’t touch those dou-dahs in
which you are so interested, but I like my cup of
coffee.”
FIRST COUNCILOR DISTRICT MEETING
(A letter from Dr. S. Rubinow, of Newark, of-
fering suggestions of value to committees arrang-
ing for meetings at which economic problems are
to be discussed.)
To the Editor: The February meeting of the
Essex County Medical Society, a joint meeting
with 4 other county societies, was devoted to
medical economics. It was, we believe, arranged
at the suggestion of the Conference of County
Secretaries, which rightfully considers this topic
at the present time of the utmost importance to
the profession. Nearly every leading man in
state and national medical organizations is aware
of the grave problems facing the profession and
is deploring the indifference of its members to
these problems. The object of these meetings is
to overcome this indifference, to arouse the pro-
fession’s interest and to create a unanimous,
strong, medical opinion and a definite attitude to-
ward the issues involved.
From this point of view one is compelled to
say frankly that the above mentioned meeting did
not fully accomplish its purpose. To begin with,
the meeting was not sufficiently advertised to as-
sure a large attendance. The presence of a num-
ber of members from the other counties some-
what saved the situation but even so the attend-
ance was poor. The addresses were excellent,
though somewhat too long, too academic. What
is to be regretted most, is the fact that the mem-
bers at large were not at all encouraged and
hardly given an opportunity to participate in the
discussion, very likely on account of the late hour.
A few officers of the state and county societies
were called upon for discussion, but one is of the
opinion that these members have other oppor-
tunities for expressing their views.
The writer of these lines believes that such
a meeting, if its importance is sincerely felt,
should have been conducted in 2 sessions, 1 de-
voted exclusively to discussion. The meeting was
held on Dincoln Day and an afternoon and even-
ing session could have been arranged with a dinner
between. The meeting could have been adver-
tised more efficiently by announcements at all
preceding medical meetings, by placing reminders
on the boards of all the hospitals; by postal
cards on the day of meeting, and so forth.
These remarks are written with no intent of
fault finding, and solely with the desire to be
helpful to other county societies, which may
contemplate similar meetings.
ACTIVE IMMUNIZATION AGAINST ME A SDKS
(Letter from Dr. Felix Baum, of Newark)
The article of Dr. Piller in the April number of
this Journal reminds me of an experiment in my
own family which might be of practical interest.
In April 1918, my second son developed measles
at the age of 3 years. In order to protect my
older son, 6 years old, who had just entered school, I
vaccinated him on the inner surface of the right
fore-arm in the usual way, making a few scratches
superficially and rubbing in a drop of nasal secre-
tion from the nostrils of the sick child. Vaccination
of the healthy boy took place at the bedside of
the patient during the stage of eruption.
I watched the fore-arm of the older boy, who
attended school and slept in the same room with
his brother. A few days after the vaccination I
noticed a slight redness and a soft movable mass,
not larger than a cherry, just under the skin of
the fore-arm, which disappeared after about 5
days. There was no fever nor pain. The boy
continued at school without showing any signs of
measles. During the epidemic in the same month
the entire class of which my boy was a member
developed measles but he stayed well and remains
immunized until today, though he is 19 years old
and has been exposed to measles repeatedly. How
long the immunity will last I do not know. In
looking over the literature, I find that numerous
attempts have been made to immunize children
actively against measles. Herrman (Arch. Pediat.,
39:607) took the nasal mucous discharge of pa-
tients before appearance of the eruption, mixed
it with saline solution, centrifuged the mixture,
added tricresol as a preservative, and applied a
few drops to the nasal mucous membrane of 4 to
5 months’ old infants to be immunized. It seems
to me more logical to use the skin, the organ of
protection, as the site of inoculation. Moreover,
direct vaccination with the virus, unchanged by
chemical or mechanical means, seems preferable
because we know that the virus is very sensitive
and can be transmitted only by direct contact.
I admit that 1 case does not prove anything,
but it indicates that an artificial, localized skin
infection with measles probably is harmless and
deserves further study in a large number of cases.
ERRORS IN “OFFICIAL LIST”
(Letter from Dr. J. B. Morrison, Secretary of the
Medical Society of New Jersey.)
Hofer, C. J. M., of Metuchen, is alive and in
good standing. The deceased physician, Dr.
Clarence A. Hofer, was also a resident of Me-
tuchen, hence the mistake.
Through a printer’s error, an asterisk was
placed before the name of Dr. Francis E. Proc-
tor, of Trenton.
Dr. Frank C. Johnson, of New Brunswick,
wishes to have reference made to the fact that
he has an office in New Brunswick and also one
in Elizabeth.
448
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
Woman’s Auxiliary
WOMEN AT THE A. M. A. PHILADELPHIA
JUNE 8-12, MEETING
(Submitted by Mrs. Walter Jackson Freeman)
The Woman’s Auxiliary to the American Medical
Association has been placed in charge of all en-
tertainment of women visitors, and began its lab-
ors on June 27, 1930, by engaging the whole Roof
Garden of the Bellevue- Stratford Hotel for the
period of the Convention. All women’s activities
will center in this hotel — -registration, meetings,
luncheons and supper dance, and all excursions
will start from the Broad Street entrance. Invita-
tions and tickets must all be procured in the Roof
Garden in advance, as nothing but programs will
be obtainable elsewhere. Members of the A. M.
A. are invited to join all excursions, and should
register for them in advance. Rooms for State
Headquarters have also been reserved in the hotel,
and sponsors will be appointed to look after all
women registered from their own states. The list
of sponsors will be printed in the program. The
Chairman of the Women’s Hotel Committee is
Mrs. Frederick S. Baldi, 2117 Porter Street, Phila-
delphia, who will be glad to make any desired
reservations.
The Convention will open with a subscription
buffet luncheon in honor of all National Auxiliary
Presidents from Mrs. Red to Mrs. McGlothlan,
immediately followed by 3 “round tables” of 35
minutes each, with 10 minutes intermissions, each
under expert leadership. The subjects will be:
(1) Programs for County Auxiliary Meetings.
(2) Technic and Value of a Committee on Pub-
lic Relations.
(3) History and Archives.
These informal gatherings will be a sort of pre-
liminary canter, designed to bring together those
interested in special phases of auxiliary work and
give them opportunity to discuss the subject
thoroughly during the following days. The Na-
tional Board Dinner and Pre-Convention Meeting
are scheduled for Monday evening.
A new and, we hope, helpful feature will be a
Question and Suggestion Box to which we beg all
with good ideas to contribute. This seems the
most practical way of finding out what our mem-
bers want continued, what discarded, and what
plans are indicated for the future.
The regular business session will be held on
Tuesday and Wednesday mornings. National
chairmen will be allowed 10 minutes for their re-
ports, State Presidents 3 minutes. Reports to be
printed may be as long as desired (within reason),
but let no one reporting on the floor imagine
these limits an idle jest. Nor will the hours an-
nounced on the program be found to mean “about”.
Have your watches cleaned and regulated, and
practice your wrist drill before leaving home. You
will need it.
Thursday morning, too, will be a busy one, the
post-convention Board meeting, a special meeting
for State and County Treasurers desiring further
elucidation fo the treasurer’s receipt blanks, and
at 10.30 an informal round table presided over by
the new president: the subject, “What Have I
Gotten Out of the Convention?” At this meeting
Mrs. McGlothlan will announce her comJmittee
chairmen and outline her plans for the coming
year, and the subjects in the Question Box will be
discussed, a sort of stock taking, closing the year’s
business and opening the new books.
Philadelphia, as an historic and culture center.
is the key-note of the entertainment planned for
our guests. Except Monday, all afternoon and
evenings will be devoted to pleasure, and a variety
of excursions is offered to suit all tastes, all physi-
ques, and all weathers. They include bus trips to
Valley Forge and to Longwood, the beautiful es-
state of Mr. and Mrs. Pierre S. du Pont; a boat
trip on the Delaware, and visits to the Fairmount
and Rodin Museums and to the Historical Society
of Pennsylvania. The Museum authorities are de-
lighted to provide decent service for those desirous
of more than a passing glance at their treasures,
and the Historical Society will arrange a special
exhibition for the week — including portraits,
prints, engravings, documents, silver, etc. — from
its unsurpassed collection of Americana. There will
also be a brief history address by Dr. Charles W.
Burr, of Philadelphia.
Wednesday will be a field day, the big auxiliary
luncheon, with guests and speakers from the A.
M. A., and a beautiful musical program, the gift
of the Delaware Auxiliary. In the afternoon, the
Philadelphia County Medical Society will invite the
women to be guests on a bus trip through historic
Philadelphia (a 10 minute’s stop at Independence
Hall), Fairmount Park and Germantown to “Sten-
ton”, where the New Jersey Auxiliary invites us
all to tea. “Stenton”, the home of James Logan,
Penn’s friend, Secretary of the Colony, still stands
just as it was built in 1728, with furniture of the
period, and garden laid out as described by con-
temporaries. On Wednesday evening, the Pennsyl-
vania Auxiliary invites all visiting ladies to a
reception in the superb Chinese Rotunda of the
Lhiiversity Museum, a setting probably unsurpass-
ed in any museum anywhere.
This meeting of the A. M. A. is the first in
Philadelphia in 30 years, and the county medical
society, desiring to mark so auspicious an occasion,
and also in appreciation of the work of the aux-
iliary, invites all members of the A. M. A. and
the visiting ladies to be its guests at a supper
dance in the Ball Room of the Bellevue, following
the big meeting of the A. M. A. on Tuesday even-
ing at the Academy of Music. The President’s
ball at the Benjamin Franklin Hotel on Thursday
evening, to which all are invited, will close the
formal festivities.
To those still able to rise from their beds on
Friday morning there are offered a tour of Wana-
maker’s with luncheon in the Crystal Tea Room;
or an all -day bus trip to Atlantic City, where the
New Jersey Auxiliary will meet them for luncheon
at the Claridge. This Atlantic City program in-
cludes also a visit to the new Convention Hall, an
hour in a chair on the boardwalk, and plenty of
time for window shopping or a swim.
And finally, every day and all day there will be
a booth in the Roof Garden inscribed “As You Like
It” — where those wishing to golf, shop, go
to Garden Days, or carry out any other pet pro-
ject not elsewhere provided for, may find in-
formation and assistance in making a profitable
use of their opportunity.
Will you not reward our efforts by the largest
and most enthusiastic woman’s attendance in the
history of the American Medical Association?
EXECUTIVE BOARD MEETING
Reported by Mrs. W. Blair Stewart.
The Executive Board of the Woman’s Auxiliary
to the Medical Society of New Jersey met at the
Stacy-Trent Hotel, Trenton. Prior to the business
meeting a luncheon was served which added to
the general friendliness of the occasion.
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
449
The program for the State Auxiliary meeting at
the Berkeley-Carteret Hotel in Asbury Park, June
3-5, was read and discussed, and the proposed re-
vision of By-Laws read and discussed.
Those attending were: Mrs. John Nevin, Presi-
dent; Mrs. H. Roy Van Ness, President-Elect; and
Mrs. Dan S. Renner, Mrs. Edward Clarke, Mrs. A.
Haines Lippincott, Mrs. George Orton, Mrs. Theo-
dore Teimer, Mrs. William Preile, Mrs. John F.
Hagerty, Mrs. H. H. V. Hubbard, Mrs. W. C.
Raughley, Mrs. Emanuel Newman, Mrs. George N.
J. Sommer, Mrs. W. Blair Stewart. The guests were
treasurers or secretaries from the various county
auxiliaries.
Gloucester County
Reported by Mrs. Henry B. Diverty
The regular meeting of the Woman’s Auxiliary
to the Gloucester County Medical Society was held
at the Woodbury Country Club on Thursday, April
16, at 9 p. m. The president, Mrs. Elwood Downs,
was in the chair and the membership was well
represented. Mrs. D. Miller, of Millville, was a
guest.
After disposing of the regular business, Mrs.
Downs read the wonderful program for the enter-
tainment of Auxiliaries attending the American
Medical Association convention to be held in Phila-
delphia June 8 to 12. This program was arranged
by Mrs. Walter Jackson Freeman, who knows
Philadelphia and knows women, and the best
Philadelphia has for a sight-seeing trip of 3 days
is on this program. Social functions as well. Head-
quarters for Auxiliary members will be at the
Bellevue-Stratford Hotel, where 2 rooms will be
at their service for the entire time — gratis.
If it is your privilege to belong to the Auxiliary
to Gloucester County Medical Society, don’t miss
it.
Professor Beardsley, who had addressed the doc-
tors in an adjoining room, was presented to us
and other visiting delegates.
After a short social session we were invited into
the dining room where a fine collation was served
by the Country Club chef.
Hudson County
Reported by Miss Anne Hetherington
The Woman’s Auxiliary to the Hudson County
Medical Society met March 27 in the Jersey City
Y. W. C. A., with Mrs. John Nevin presiding.
A Nominating Committee for the coming elec-
tion was appointed: Mrs. J. S. McDede, chairman;
assisted by Mrs. W. Duckett, Mrs. P. Maras, Mrs.
A. Ruoff. Delegates to the State Medical Auxiliary
Convention at Asbury Park in June are: Mrs. IT.
Klaus, Mrs. W. Duckett, Mrs. S. Barishaw, with
Mrs. Freile, Mrs. F. Nicholson and Miss Anne
Hetherington as alternates.
After the business meeting the Auxiliary was
addressed by Mr. J. Coleman, Secretary of the
Jersey City Health Council, whose subject was
“New Developments in the Field of Tuberculosis’’.
The Hudson County and Jersey City Boards of
Health are distributing pamphlets on tuberculosis
in the schools, stressing early diagnosis and pre-
ventive hygiene to the older boys and girls. They
have tried to make this literature as appealing as
possible to arrest the attention of the young.
Some pages are given to items of varied interest
with an occasional biographic sketch. In the last
issue appears the Life of Laennec, inventor of
the stethoscope.
Mr, Coleman cited many of the causes of tuber-
culosis, among them being the scanty dress of
the modern girl; industrial occupations; crowded
living conditions; but declared malnutrition, in-
duced by Hollywood diets and the craze for slen-
derness, to be the most fertile source of the dis-
ease. Fortunately, this destroyer of the young,
even in its advanced stages, responds to nutrition-
al therapy.
Tuberculosis is found in varying degrees among
different races; the lowest death rate is held by
the Jewish people, who have developed an immun-
ity to this disease which is offset by a proneness
to nephritis and diabetes. The Italian death rate
is the next lowest; the highest is suffered by the
Irish and colored races. In his native south, the
negro shows comparative freedom from this dis-
ease, but transplanted to other cities, he becomes
easy prey. The health boards intend to make great
efforts to educate the negro in preventive measures.
After Mr. Coleman’s address an open discussion
was held.
Tea and the usual social hour followed.
Hunterdon County
Reported by Mrs. J. D. K. Tompkins
The spring meeting of the Woman’s Auxiliary
to the Hunterdon County Medical Society was
held at the home of the President, Mrs. F. A.
Thomas, in Flemington, on Tuesday, April 21.
Following the meeting a delicious luncheon was
served by the hostess.
Union County
Reported by Mrs. C. A. Hoffman
The regular quarterly meeting of the Woman’s
Auxiliary to the Union County Medical Society
was held in the Nurses’ Home of the Elizabeth
General Hospital, Elizabeth, on April 8, with Mrs.
Hubbard presiding. There were 24 members pres-
ent. Minutes of the previous meeting were read
and approved.
Mrs. McElhinney, Treasurer, reported a balance
on hand of $35.36. Monthly" reports were called
for. Delegates were appointed to the American
Medical Association Convention to be held in Phila-
delphia the first week in June: Mrs. Harry V.
Hubbard, of Plainfield, and Mrs. G. S. Laird, of
Westfield; Alternates, Mrs. H. D. Corbusier, of
Plainfield, and Mrs. F. A. Kinch, of Westfield.
Mrs. John Nevin, of Jersey City, President of
the Woman’s Auxiliary to the State Society, was
present and gave a review of a book by Gertrude
Atherton, “The Conquerer”, and also commented
upon other authors, including Sinclair Lewis and
Booth Tarkington.
An interesting address on “How to Make a
Small Garden’’ was given by Mrs. R. A. Shirrefs,
of Elizabeth.
A door prize was given, and was won by Mrs.
De Cesar, of Bozelle Park.
A delightful afternoon at cards, following lunch-
450
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
eon, was enjoyed by more than 20 members at the
Clare Louise Tea Shop, in Plainfield, on March 1G.
Members were present from Elizabeth, Westfield,
Cranford, Rahway and Plainfield. Pour prizes were
awarded, the first going to Mrs. G. S. Laird, of
Westfield. The door prize was won by Mrs. F.
A. Kinch, of Westfield.
County Society Reports
ATLANTIC COUNTY
Fifth Councilor District, Medical Society of
New Jersey
John Irvin, M.D., Reporter
The third annual meeting of the Fifth Councilor
District of the Medical Society of New Jersey,
comprising Atlantic, Cape May, Cumberland,
Gloucester and Salem Counties, was held in Atlan-
tic City April 10, with Dr. Joseph H. Marcus act-
ing as chairman. Dr. Marcus welcomed members
and guests from the other counties, and went on
to explain the purpose of the meeting. Extension
of the Councilor District meeting plan to the entire
state was proposed at the November meeting of
County Society Secretaries and Reporters. The
purpose is in part to discuss the economics of
medicine and state medicine in order to inform
our members what is going on and in order to
keep them in touch with ever-changing conditions.
So, it is my very great pleasure to introduce Dr.
Hartwell, who is President of the New York
Academy of Medicine, and whose topic will be
“The Continued Education of the Doctor”. (To be
published in the June Journal.)
Dr. Marcus: Dr. Hartwell has presented to you
facts that have been gathered from years of ex-
perience. Our next speaker brings with him a
wealth of experience, from a clinical as well as
an institutional point of view. He is a clinician
of note in Philadelphia and it is my great pleasure
to introduce Dr. Jospeh C. Doane, Medical Di-
rector, Jewish Hospital, Philadelphia, who will
speak on the subject: “What the Public Thinks of
Present Day Practice of Medicine.’’
Dr. Doane: It goes without saying that I con-
sider myself able to speak about the current prob-
lem that is confronting the medical profession. If
I am a trifle vitrolic, a trifle caustic, in regard to
our own profession, let me say it isn’t time for
platitudes when one is trying to find out who is
muddying the water. One can hardly go into a
Pullman car without hearing someone relate some
unpleasant experience that a relative or friend has
had at the hands of a physician. We are passing
through a changing economic and political exist-
ence. Perhaps the doctor and society will have
to have adjustments from the standpoint of finan-
cial relationships downward or upward to suit the
needs of the individual. Certainly there is some-
thing in the water which is muddying it. Whether
the fault lies with the patient or the physician it
is hard to say, but we will have to purge our
ranks of the unethical, the pretenders, those
whose names may carry the M. D. but who do
not have the welfare of the patient or the physi-
cian at heart. It seems to me that the profession
must separate itself from those who are doing it
harm, and the public cannot judge and will not
judge on generalities. The people desire to deal in
specific instances. Medical Societies should as-
sume a more militant leadership.
In Pittsburgh, for example, no Medical Director
is appointed without approval of the medical so-
ciety. In many other localities, where leadership
is needed, rarely do they turn to the medical so-
ciety for advice. The Philadelphia County Medi-
cal Society has been asked by 2 of the city’s lead-
ing papers to censor all medical advertisements.
Certain broadcasting stations have promised that
all members advertising, whether it be about medi-
cal appliances, apparatus or anything to do with
medicine, will be submitted for careful censoring
by the local medical society. (Dr. Doane’s paper
will appear in the June Journal.)
At the close of the afternoon session all mem-
bers and guests attended dinner in the hotel, at
which the principal speaker and Guest of Honor
was Dr. H. Sheridan Baketel, Professor of Hygiene
in Long Island Medical College, and Editor of
“Medical Economics”. (Dr. Baketel’s address to be
published later in the Journal.)
In the evening a Clinical Session was held at the
Atlantic City Hospital, where members of the staff
exhibited patients and discussed a wide variety
of disease conditions.
The attendance at this District Meeting was
greater than in preceding years and was stated
by Dr. Reik to be larger than the number reached
at any other District Meeting in the state.
Among those present was Dr. George N. J.
Sommer, President of the State Medical Society,
who responded to a call from the chairman and
delivered a short talk at the banquet table.
This meeting was considered in every way suc-
cessful.
BERGEN COUNTY
C. H. Littwin, M.D., Reporter
The regular meeting of Bergen County Medical
Society was held April 14, at the Englewood Hos-
pital, with Dr. Joseph Morrow presiding. The
minutes of the last meeting, and also of the meet-
ing of the executive committee, were read and ap-
proved.
Dr. Morrow announced the appointment of the
Public Health Nursing Committee: Drs. Edward
W. Clarke, Chairman; Payne, Pallen, Sarla, James
and Knowles.
The membership application of Dr. Neil McL.
Whittaker, of Hackensack, was read. The follow-
ing were elected to membership: Drs. Thomas F.
Reid, Joseph A. Rowe, William F. Fitzhugh, and
A. Ivan Mader, Jr.
The Secretary announced the omission of Dr.
Herman Trossbach's name from the program
through an oversight. Dr. Trossbach attended the
meeting of the American College of Physicians at
Baltimore as the first member from Bergen
County.
A communication from Wm. J. Ellis, Commis-
sioner of Institutions and Agencies, urging atten-
dance at the Child Welfare Conference in New
Brunswick, was read.
Dr. Wolowitz announced the progam for the
Post-Graduate Course in Gynecology and Obstet-
rics, which is to be given at the Hackensack Hos-
pital on Friday afternoons beginning May 1.
Mention was made that Dr. Levitas had given a
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
451
dinner before the meeting to the speaker of the
evening and a number of his friends on the
occasion of his 25th anniversary of practice in
Bergen County. He was presented with a silver
cocktail shaker by the Medical Board of Hacken-
sack Hospital.
For the scientific program, Dr. Burton J. Lee,
Professor of Surgery at Cornell University Medi-
cal School and Attending Surgeon at Memorial
Hospital, spoke on the “Indications for Surgery or
Irradiation in Treatment of Cancer”; illustrating
his talk with lantern slides. As a member of the
American College of Surgeons’ Committee on
Establishment of Cancer Clinics, Dr. Lee’s par-
ticular plea was for establishment of a Cancer
Clinic in Bergen County for earlier diagnosis and
better treatment. Drs. Pallen, Levitas and A. W.
Ward discussed the question, and on motion of
Dr. Levitas the president was ordered to appoint
a committee to consider the formation of such a
clinic.
CAMDEN COUNTY
Robert S. Gamon, M.D., Reporter
The regular monthly meeting of the Camden
County Medical Society was held in the Camden
City Dispensary on April 7, with Dr. W. J. Bar-
rett presiding.
Dr. E. A. Y. Schellenger was sworn in as a
member.
The Scientific Program was given by 5 mem-
bers who are qualified oculists. Dr. Pierce Shope
read an article on “Refraction and Health”. An
interesting paper was presented by Dr. A. T.
Eaton on ‘‘Eye Grounds in Some Medical Dis-
eases”. This was illustrated with lantern slides.
“Squint in Children and Its Effect in Later Life”
was read, and illustrated by lantern slides, by
Dr. W. G. Mengel. Dr. Shipman presented a
paper entitled “Significance of a Red Eye; with
Some Remarks on Glaucoma”, using lantern
slides to illustrate his remarks. “Some Com-
mon Conditions in Industrial Ophthalmology”
was given by Dr. G. J. Dublin. Moving Pictures
of Cataract Operations, taken by Dr. Frank Par-
ker of Wills Eye Hospital, were also presented.
Each paper was well presented and received
favorable comment from the members present.
CUMBERLAND COUNTY
E. S. Corson, M.D., Reporter
Newcomb Hospital, Vineland, again opened its
hospitable doors to the Cumberland County Medi-
cal Society, on April 14, when 2 distinguished
physicians addressed the society, and a resolu-
tion was adopted advocating a county hospital
for tuberculosis patients.
-One of the first things was introducing new
members: Drs. G. A. Davies, Elmer; Charles
Cunningham and H. B. Walker, of Vineland;
Charles B. Neal and Fred V. Ware, of Millville.
A resolution endorsing a movement of the
County Committee of the American Legion, to
petition the County Freeholders to provide a hos-
pital for tuberculous patients, was passed. “The
difficulty in securing places for these patients,
the cost of transportation and visiting them, the
delay in entering them until it is too late for a
cure, and the infection of associates, make it
necessary to seriously consider taking care of
our patients at home”, it was stated.
Dr. Reba Lloyd, president, felicitated herself
in a gracious manner on being able to present
as guest speakers, 2 professors of her Alma Ma-
ter, the Women's Medical College of Philadel-
phia.
Dr. Catherine MacFarlane, Germantown, dis-
cussed “The R61e of Focal Infections in Disease
of the Urinary Tract”. Focal infection is an out-
standing discovery of American doctors. It is
now readily determined that infected tonsils and
teeth may cause infection of the kidneys and
bladder. The findings in 100 cases clearly evi-
denced this statement. Several speakers gave
personal illustrations of how cures of rheuma-
tism, bladder disease and neuritis had promptly
disappeared on removal of the causes as stated
above.
Dr. J. Stewart Rodman, Philadelphia, traced
the growth of the efforts to cure and prevent
“Cancer of the Breast”. The female breast,
owing to its function, is more liable to become
affected. A simple inflammation of the milk
ducts may eventually end in cancer. Attention
to this condition should be given at once. At
present a 5 years’ delay of fatal terminations has
been secured in 50% of the cases operated on,
and less loss of function has resulted than form-
erly. With the extensive investigation that is in
progress, the discovery of a cure cannot long be
delayed. He explained a modification of the Hal-
sted operation, to prevent contraction of the
scar. A vertical incision, a few inches from the
insertion of the pectoral muscles is made, in-
stead of carrying to the usual point.
ESSEX COUNTY
E. LeRoy Wood, M.D., Reporter
Considerable attention was given to economic
problems at the Essex County Medical Society
meeting held Thursday evening, April 9, at the
Academy of Medicine, Newark. The president.
Dr. Henry C. Barkhorn, first called attention to
an ethical and economic problem involving the re-
lationship of one physician to another. There is
great complaint by many doctors against physi-
cians employed by insurance companies operating
under the Workmen’s Compensation Act. An in-
jured workman places himself under the care of
a doctor of his choice. Shortly, another doctor,
employed or influenced by an insurance company,
“lifts” the patient from the care of the first one.
The idea was expressed that such conduct is just
as unethical as the taking of other than compen-
sation patients from another doctor. It was stated
that while the patients may be influenced by in-
surance company agents to change from an out-
side physician to an insurance or company doctor,
the latter is party to an unethical act, and such
conduct was condemned by the society through
passage of a resolution.
In the discussion, it was pointed out that con-
duct by a physician contrary to the ethical stand-
ards of the County Society might cause that physi-
cian to lose membership. As many hospitals and
other organizations require County Society mem-
bership of staff members, the result of unethical
conduct might be far reaching in its effects. Con-
duct contrary to code principles, by insurance doc-
452
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
tors, may cause them to take a place outside of
organized medicine.
Dr. Barkhorn then introduced Dr. Linn Emer-
son, who read a paper entitled “Economic Phil-
osophy for the Present Day Doctor”.
Dr. James S. Plant, Director of the Essex County
Juvenile Clinic, taking as his subject “The Essex
County Juvenile Clinic and the Medical Profes-
sion”, spoke as follows:
The Essex County Juvenile Clinic was organ-
ized in 1923 by the Board of Chosen Freeholders
of Essex County. It is supported by that Board
and is cpunty-wide in its work.
It is not fair to judge the Clinic without know-
ing something of the philosophic trends which
were back of its construction. There were at
least 2 distinct movements of which this was a
result. Beginning in 1900. with establishment of
the Juvenile Court in Chicago under Judge Julian
Mack, and flowering out of this in 1911 into estab-
lishment of the Psychiatric Clinic in conjunction
with that Court, we have developed in the legal
field the psychiatric point of view. Psychiatrists
are physicians and if they are interested in con-
duct disorders (delinquencies, maladjustment,
crime) they look upon such disorders as simply
symptoms of some deeper trouble. The lawyer is
always interested in the exact degree of delin-
quency or crime. We have in psychiatry assumed
the attitude of wanting to know why a delinquency
occurred, and this involves such a study of the
patient and his environment as will show the de-
linquency to be just the natural outcome of funda-
mental stresses in the child’s life.
An entirely different movement was running
parallel with this in the field of mental disease.
With the birth of modern psychiatry, in 1890,
with the work of Pinel, there developed a group of
better mental hospitals, but there was a growing
conviction that such hospitals were simply treat-
ing end-results. Thus, when Beers, in 190G,
popularized the notion of the understanding and
prevention of mental difficulties he found the
psychiatrists in a receptive mood. Here began the
notion that we should try to understand people
who were disturbed, before they became sufficiently
disturbed to go into a mental hospital. This is
not true prevention although it has often been
called so. That is, there is no true prevention in
simply trying to get a disease process just a little
bit earlier than you had before. We have seen in
the matter of physical disease the ultimate neces-
sity (in true prevention) of ameliorating those en-
vironmental conditions which give rise to the dis-
ease. That is true prevention. We prevent typhoid
by watching our water reservoirs and the cows at
the dairies. We prevent tuberculosis by building
better houses. I submit that we can only really
prevent mental breakdown of one sort and an-
other by an understanding and control of all those
great cultural forces which give rise to such diffi-
culties.
As I picture these social applications of psychi-
atry, may I draw your attention to an interesting
correlated development in the field of biology. The
biologist is today definitely accepting the cell and
its environment as a continuum. In other words,
it is more and more recognized even in the biologic
field that individuality in the sense that we have
thought of it in the past, does not exist: that there
is such a set of reactions and interactions be-
tween the individual and his environment as
makes it utterly impossible to think of them as in
any sense separated. This gives you a picture of
the philosophic basis.
The work is carried on in such way that after
a youngster has been referred to us we try to
make a thorough physical, psychologic, psychiatric
and social study of him in an effort to find out
why he got into his difficulty. Roughly, in about
Vs of the children we find a physical source of
difficulty that is primary; i.e., primary in the
sense that it is the important causative factor. For
instance, we have a truant who doesn’t want to
go to school because he can't sit still there. We
find, even in our own county, that many times
such a child has been given a seat in the front of
the room facing the other children so that -he will
stop his everlasting wiggling. So, we often find
chorea, bad tonsils, bad teeth, or constipation as
the sole major source of the difficulty.
I should like in addition to call to your attention
what I might term physical factors as “indirect”
causes. I am referring to such matters as short
stature, birth-marks, being “plain”, unusually
large stature in girls, and that sort of thing —
where the physical difficulty is of itself not im-
portant but where it makes the child feel that he
has much to compensate for because he has thus
been set apart as different, odd and strange. Per-
haps the most desperate criminal I have ever
known was a boy who grew up as a “runt”. He
compensated for all of this feeling of inferiority by
a series of amazing crimes.
In something like 30% of our cases mental de-
fect in one form or another is a major factor.
Here, of course, we have chiefly the inability on
the part of the child to successfully meet the
academic requirements of the school. One of the
most interesting of problems arises out of the
fact that as we mechanize and automatize our
culture, we rather tend to place a premium upon
feeble-mindedness. That is, we must remember
that the job which has little of satisfaction in it-
self, as a job, is perhaps peculiarly adapted to the
handicapped youngster.
This leaves us some 55% of children who are
pretty normal individuals physically and mentally,
with whom the problem is that of adjustment. I
tend, with this group, to think of 3 steps of com-
plexity of adjustment. Of course you cannot
schematize life but perhaps it isn’t too mechani-
cal to follow this outline. In the first adjustment,
we have what we would call the “family” period;
they come to us with the problems of thumb-
sucking, enuresis, temper tantrums — all of those
affairs which have their basis in poor habit train-
ing by the parents. The parental dissatisfactions,
the parental disappointments, the parental rest-
lessness, nervousness and artificiality, here play an
important part. We have the feeling that these
habit problems that go to the pediatrician are very
difficult of understanding if the pediatrician looks
at the problems solely from the point of view of
the child. It is so difficult to understand, for in-
stance, the mother’s overweaning interest in the
child’s development if we do not understand the
relationships which she has with her husband and
other members of the family.
Secondly, there is the period of socialization —
that period beginning at the age of 4 or 5 years,
when the child leaves his family to compete with
the child of the street and the school. There come
all of the problems of shyness, poor companion-
ship, of the effort to establish one’s self in the com-
munity in whatever way seems easiest. So many
of the problems of the court and school, problems
of mischief, problems of making faces, of antics,
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
453
of raising the devil, are only the child’s simplest
way of making himself the center of attraction.
Thirdly, we have the period of sexualization — all
of those problems that come from the child’s at-
tempt at solving the difficulties arising from de-
velopment of his or her sexual life. A boy started
to stammer at 13, and came to me at 16 because
he simply couldn’t talk to any other person. He
was a shy and rather difficult boy, rather typi-
cally a Froelich’s syndrome, who suddenly dis-
covered at 13 that his genitalia were very unde-
veloped in comparison with other boys. He was,
of course, simply beside himself, felt that he would
never be a success, that he could never make his
way with others, and the stammering appeared,
and got worse, because he couldn’t bring himself
to make any sort of social adjustment.
What is the relationship of this work to the
medical profession or to the County Medical So-
ciety? Only opinion can be given and in what
further I have to say to you I should like to have
you realize that I am giving only my own plan. It
has been my good fortune during the past year to
be working on a committee of the White House
Conference on Child Health and Protection which
has been interested in precisely this problem. We
have come to certain conclusions and these, in
part, I am presenting to you; but they are again,
of course, presented purely as one way only of
looking at the problem.
The psychiatrist’s work can be rather easily di-
vided into that which forms a technic and that
which is a point of view. The psychiatric point of
view involves: (1) seeing a conduct problem as
purely a symptom of deeper stresses in the per-
son’s life. (2) having a high regard and respect
for the child himself. I am amazed at the number
of children who come to me after having been to
many other physicians and who find in me the
first person who has really interested himself in
the way the child looks upon his own physical and
social problems. I am interested, in the younger
child, with the number of times that the pediatri-
cian seems to forget that it is the child himself
who is wetting the bed. One would think from
the work of many physicians that it was the
mother who was the person to be worked with in
the matter of the enuresis; seeming somehow to
forget that it is not she but the child who is
presenting the difficulty. Frequently it seems
never to have occurred to anyone to talk with the
child about it and to find out the way that the
child looks at it.
(3) Placing of high value upon non-verbal modes
of communication; I mean to cover all of that
group of fallacies built on the notion that a child
understands only what is said to it. As a matter
of fact the child rarely is interested in what is
said to him, and is almost entirely governed by
the way in which the thing is said and the man-
ner of conversation that is held about him. It is
startling to recognize the extent to which physi-
cians discuss a young child with the mother, in
the child’s presence, saying of course that the
child doesn’t “understand the language”. It is our
experience that in this situation the child is often
the only one in the room who really acutely and
tragically catches the meaning and the import-
ance of the stresses involved.
(4) Accepting the notion that the parents and
others who surround the child so much live out
their lives in the child’s life.
These are some of the factors in what I would
call the psychiatric point of view; what Dr. Meyer
calls “being psychiatrically intelligent”. It is my
hope that all physicians will be trained in these
matters and it is my belief that the task of the
Essex County Juvenile Clinic is to further the
spread of “psychiatric intelligence” in the medical
field.
This is all rather in contradistinction to the
various types of psychiatric technic that have de-
veloped; highly complicated modes of psychiatric
treatment. Probably such an institution as the
Juvenile Clinic will turn to the psychiatrist as a
specialist just as it turns to the surgeon or the
orthopedist. I am trying here to make the clear-
est distinction between a way of looking at things
and a highly specialized technic in psychiatric
treatment, with, of course, the hope that in time
such an institution as the Juvenile Clinic will not
be needed, as we gradually bring into our medical
practice the psychiatric point of view which is
its chief aim at the present time.
May I briefly say to you that there is a move-
ment in the medical schools toward getting away
from specialties as specialties. That is, there is a
growing tendency to get back to the point of view
of the general physician, where the patient is
looked upon as an integrated, acting whole. In 2
of the medical schools, Harvard and Johns Hopkins,
there is a very definite tendency to give all stu-
dents some conception of the environmental
stresses in human relationships that play upon the
patient. These are very hopeful signs. To these
I may add my own hope that the medical man of
the future will more and more understand the wide
usefulness of the social worker. The family goes
to the physician for advice about its most sincere
problems. To these problems the physician is now
to a large extent blind because he is not interested
in his patient as a working, reacting mechanism,
but only as a group of viscera, skin and bones. I
make this appeal, that you look toward a situa-
tion which will find you giving help to parents in
matters of the total social adjustment of their
children, and of themselves, simply because you
are the logical persons to do it, because the family
looks to you to do it, and because if you don’t do
it you will find that in the field of conduct dis-
orders, just as in many other medical fields, the
quack, the charlatan, the poorly-prepared person,
will come in to help the family simply because you
will not accept a tremendously challenging and
interesting burden which the family would very
much prefer that you carry.”
The following 7 new members were elected: Rose
W. Bass, Bernard Fein, Philip Grossblatt, Gil-
christ B. Matheson, John J. Reilly, James H.
Trainor and Maurice M. Weinberg.
Academy of Medicine of Northern New Jersey
Eye, Ear, Nose and Throat Section
E. LeRoy Wood, M.D., Secretary
At the meeting of the Eye, Ear, Nose and Throat
Section of the Academy of Medicine of Northern
New Jersey held Monday evening, April 13, the
Chairman, Dr. J. Wallace Hurff, announced the
following committee to investigate and consider
the problem of the high cost of eye-glasses and to
recommend a solution: Drs. Dennis F. O’Connor,
Dinn Emerson, Brayton E. Failing, William H.
Hahn, Elbert S. Sherman, Andrew Rados, William
F. Krone, Charles W. Buvinger, George J. Holmes
454
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
ancl Lee W. Hughes; the first named being chair-
man.
The following officers were elected for the en-
suing year: Charles W. Buvinger, Chairman; E.
LeRoy Wood, Secretary.
Dr. Hurff then introduced Dr. John McCoy, of
New York City, who spoke on “Successful Treat-
ment of Chronic Discharging Ears and Nasal Ac-
cessory Sinuses by Means of Zinc Ionization".
Dr. McCoy : My object in presenting this paper
is to give my results and conclusions after using
the method of zinc ionization during the past few
years. It was first practiced by Dr. Le Due, of
France; later, by Dr. Friel, of England..
If we review briefly what takes place when zinc
ionization is practiced, we find that ionization is a
chemical decomposition effected by means of an
electric current. There are certain laws govern-
ing this decomposition. Ions are groups of atoms
which result from the electrolytic decomposition
of a molecule. These ions are either electro-nega-
tive or electro-positive. The electro-negative ions
are called anions; electro-positive ions are called
cathions. Hydrogen and the metals generally are
cathions. The electro-positive ions, or cathions,
tend to flow toward the negative pole. It has been
found that by use of a solution of sulphate of zinc
at the positive and the ordinary saline solution at
the negative pole, it is possible to drive zinc ions
into the exudate and into the membranes of the ear
cavities. Some have gone so far as to claim that
such a procedure will cure chronic necrosing mas-
toiditis. Our observations have not borne this out.
They have proved to us, however, that this method
will cure many cases which generally are regard-
ed, from their symptoms, as being chronic middle-
ear and mastoid necrosis.
In cases where there exists a posterior marginal
perforation, or one in Shrapnell’s membrane with
bone necrosis and foul-smelling pus, this method
should not be used. It has proved exceedingly use-
ful, however, in cases of subacute and chronic
discharge where the perforation is central or near
the margin, and where numerous other methods
used for chronic suppuration have failed. Before
resorting to its use we believe that symptoms of
extension to structures adjacent to the middle
ear and mastoid should be ruled out, as far as
possible, by means of x-ray pictures of the mas-
toid and by careful examination of the labyrinth.
The ear is thoroughly cleansed with warm
water. A pledget of cotton containing 4% cocain
solution is then applied to the middle ear for a
period of 5-10 minutes. The patient is then placed
upon a table with the diseased ear upward. After
the pledget of cotton has been removed, the ear is
filled with a 1% or 2% zinc sulphate solution and
the zinc electrode attached to the positive pole is
placed in the ear through a vulcanite speculum
(McCoy’s modification), so that the zinc electrode
and the zinc sulphate solution are in contact. The
patient is then given the other pole to hold in
the hand, or it is applied to the arm, being very
wet with saline solution. Current is then turned
on very gradually until a strength of 3 m.a. is
reached. This is continued for 10 minutes, when
the current is very gradually turned off. Un-
pleasant effects sometimes take place in the shape
of slight dizziness or slight pain in the region of
the eustachian tube, but they are very evanescent.
By this method the writer has treated a number
of cases with results that were surprisingly
gratifying, the patient’s ear condition drying up
in 2-6 treatments, the treatments being adminis-
tered once every 4 or 5 days.
Zinc ionization of the nose is practiced in the
following way: The nose is cleansed with warm
saline solution, a solution of 4% cocain is applied
to the part to be treated for a period of 5-10 min-
utes, usually with a pledget of cotton. The cavity
to be treated is then filled with a 2% zinc sulphate
solution or cotton wet with 2% zinc sulphate is
applied to the part to be treated. Now, the zinc
electrode attached to the positive pole is placed in
the nose so that the zinc electrode and the zinc
sulphate are in contact. The patient is then given
the other pole to hold in the hand. The current is
then turned on very gradually until a strength of
4 to 8 m.a. is reached. This is then allowed to
continue for 10 minutes, when the current is very
gradually turned off.
About 3 years ago, a doctor presented himself
at my office for a discharge of mucopus from the
antrum, with symptoms of focal infection, and this
was after having had 3 major intranasal opera-
tions. My advice was to have the antral opening
made a little larger, but he said that he was
through with operations and wished to try any
other means. I then thought of zinc ionization
and applied it to his antrum. This was subse-
quently twice repeated, 4 and 8 days later, with
the result that the antrum completely dried up
and for 2 years or more it has remained dry.
GLOUCESTER COUNTY
Henry B. Diverty, M.D., Reporter
At the Woodbury Country Club on April 16,
physicians of the Gloucester County Medical So-
ciety met in regular session. An informal inter-
esting talk was delivered by Professor E. J. G.
Beardsley, of Jefferson College, Philadelphia.
Delegates present were: Dr. and Mrs. Miller,
of Millville; Dr. Markes, from Woodstown, and
Dr. Church, of Salem County. The following lo-
cal members were present:
Drs. I. W. Knight, R. K. Hollinshed, of West-
ville; W. J. Burkett, of Pitman; H. M. Fooder,
of Williamstown; J. Harris Underwood, Duncan
Campbell, E. E. Downs, C. A. Bowersox, William
Brewer, Paul Regau, H. B. Diverty, all of Wood-
bury; H. L. Sinexson, of Paulsboro; C. I. Ulmer,
of Gibbstown; A. B. Black, of Mickleton; C. C.
Sheets, also of Paulsboro, and C. C. Krusen, of
Mullica Hill.
A luncheon was served by the caterer.
HUDSON COUNTY
E. G. Waters, M.D., Reporter
The regular meeting of the Hudson County
Medical Society was held on April 7, at the Car-
teret Club, in Jersey City. Dr. J. M. Cassidy pre-
siding. The minutes of the March meeting were
accepted as printed in the Bulletin.
The following communication from Dr. Cole-
man was read, and having been favorably re-
ported upon by the Executive Committee, was ap-
proved:
“The assumption by Congress, in the Volstead
Act, of control over the practice of medicine in
the United States has raised the most serious
.May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
455
questions that have ever confronted the medical
profession: (1) The right of the several states
to regulate the practice of medicine within their
borders; and (2) the right of the individual
physician to treat patients according to his train-
ing and experience.
These questions have no relation whatsoever
to prohibition as such; alcohol was merely the oc-
casion of the assumption of the above-mentioned
powers by Congress. Under other circumstances,
Congress might forbid the use of toxin-antitoxin
or forbid more than 3 grains of caffein a day.
The right of the state to regulate the prac-
tice of medicine within its borders concerns the
members of the medical profession only as citi-
zens.
The right of the physician to the untram-
meled exercise of his judgment concerns the wel-
fare of his patients and his own freedom of ac-
tion.
There were 2 ways of meeting the attack by
Congress on the medical profession. (1) By test-
ing the constitutionality of the medical provisions
of the Volstead Act in the courts, and (2) by di-
rect demand by the members of the medical pro-
fession upon Congress for relief.
The first method was tried and failed. -A
group of New York physicians organized the As-
sociation for the Protection of Constitut'onal
Rights consisting of 928 members in New York
and neighboring states to light for the traditions
and the rights of the medical profession. Dr.
Samuel W. Lambert was elected president of the
Association and under the auspices of the Asso-
ciation brought suit against the Government
(Lambert v. Yellowley). An adverse decision
was rendered by the United States Supreme
Court.
If relief is to be had from the condition which
exists, the individual members of the medical
profession must now demand of Congress that
the medical restrictions of the Volstead Act be
repealed. Congress will probably listen to this.
In order to promote this action the enclosed
resolution, sponsored by the Association for the
Protection of Constitutional Rights, is being sent
to a number of organizations for consideration.
The greater the number of medical organizations
that adopt it, the sooner will the prerogatives of
the profession be restored.
It should be added that the Association for the
Protection of Constitutional Rights is in favor
of stringent regulations to control the use of al-
cohol by physicians and of severe penalties for
“violation of the regulations. This will afford pro-
tection to those physicians who believe in, and
use, alcohol in their practice and will at the same
time restrain any physician who might be in-
clined to abuse his privileges.
If the resolution meets with your approval,
would you be willing to present it to your State
Society for action?
Samuel W. Lambert, President
James F. McKernon, Vice-President
F E. Sondern, Treasurer
Warren Coleman, Secretary
John A. Hartwell
Samuel A. Brown
Harlow Brooks
Charles L. Dana
Nathan B. Van Etten
J. Bentley Squier
George David iStewart
T. C. Chalmers
Linsly R. Williams
James T. Gorton
Executive Committee.
Association for the Protection of Constitutional
Rights.
PROPOSED RESOLUTIONS FOR PRESENTA-
TION TO COUNTY SOCIETY
WHEREAS The Congress has undertaken to
fix doses of wine and whiskey and brandy by leg-
islative fiat, thus taking ovqr the functions of
pharmacologist and physician, and
WHEREAS the Volstead Act compels physi-
cians to betray the confidences of their patients
by keeping a record of their diseases and ail-
ments for inspection by Federal prohibition
agents, thus violating the traditions of the medi-
cal profession, medical ethics and the laws of a
number of states, and,
WHEREAS relief from these conditions has
been sought in the courts and has been denied
by the United States Supreme Court, and
WHEREAS the Wickersham Commission has
unanimously made the recommendation: (1) ‘Re-
moval of the causes of irritation and resentment
on the part of the medical profession by: (a)
Doing away with the statutory fixing of the
amount which may be prescribed and the num-
ber of prescriptions. (b) Abolition of the re-
quirement of specifying the ailment for which
liquor is prescribed upon a blank to go into the
public files, (c) Leaving as much as possible to
regulations rather than fixing details by statute’.
BE IT RESOLVED — That the Medical Society
of the County of New York hereby formally ex-
presses its disapproval of those portions of the
Volstead Act which invade the right of the State
of New York to regulate the practice of medicine
within its own borders and which deprive the
physician of his right to the free exercise of his
judgment in the practice of his profession, and
BE IT RESOLVED — That the Medical Society
of the County of New York demands of Congress
the repeal of said portions of the Volstead Act,
and
BE IT RESOLVED — That the Medical Society
of the County of New York urge each of its mem-
bers to demand of his Senators and Congress-
man the repeal of said portions of the Volstead
Act, and,
BE IT FURTHER RESOLVED — That the Sec-
retary of the Medical Society of the County of
New York be, and hereby is, instructed to trans-
mit a copy of these resolutions to the Senators
from New York and to each Representative in
Congress of the County of New York.”
It was moved and seconded that the. papers for
the evening be presented and discussed before
the balance of the business session.
Dr. Edward G-. Waters read a paper entitled
“Plan for County Society Control of Periodic
Health Examinations”.
In presenting this plan of periodic physical
examinations and publicity to the medical profes-
sion, I do not attempt to advise medical men as
individuals on how to handle their patients and
business. I present it as a practical plan to meet
serious and unfair competition, and to offer some-
thing of real value to our public as a whole
which must react favorably for the physician.
It can be characterized even as a measure to re-
store to us that degree of public confidence
which our more vindictive critics believe we have
lost. While this plan has been fomenting in my
mind, I have heard myriads of complaints and
read many papers about medical economics, but
a paucity of practical advice or definitive sug-
gestions. The thought has resolved itself into
456
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
a form which I believe is applicable to the vast
majority of communities in this country, with
hut few alterations.
For the purposes of clarity and reference, I
have divided the plan info 4 major component
parts, which I will now present in some detail:
(1) The adoption of a form of procedure for
periodic physical examinations with delineation
of minimum requirements for the examining
doctor to meet. This is obviously the keystone.
Any examination of this sort must be thorough
and complete. A cursory examination of the
heart and lungs, often through a half-unbutton-
ed shirt, isn’t worthy of a name. Likewise,
every thorough examination of the heart and
lungs, but neglecting, for example, a rectal ex-
amination, lacks completeness. The patient must
be stripped and ready for a complete examina-
tion, for halfway measures are not sufficient. To
remove haphazardness and prevent omissions, a
form of procedure is planned which constitutes
a written list of examinations made from head
to foot, but lists only those which any practicing
physician should be competent to make. It does
not include specialized examinations, as for ex-
ample, a retinoscopic and sigmoidoscopic ex-
amination, but would include visual eye tests, and
a rectal examination. When specialized exam-
inations are required, as for example, retinoscop-
ic, sigmoidoscopic or cystoscopic, it will be feas-
ible and highly practical to refer the patient for
these examinations to qualified men, such exam-
inations tc be part of the general examination
and in no sense to constitute a "consultation”.
The patient may thus be insured a thorough and
adequate examination with "reference” but with-
out “consultation”. The specialized examina-
tions will of course add to the charge made, if
the patient follows the general examiner’s ad-
vice who suggests them, but he knows in ad-
vance why they are requested and what the ex-
tra work entails, apart from the regular form of
examination.
(2) The adoption of a standard fee for the
community. It is imperative for the success of
such a plan that a fee be charged which is not
only compatible with the ability of the average
examinee to pay, but which is also standard
among those physicians who enroll as county
medical examiners in given communities. The
fee must at least meet or better that charged by
lay-controlled groups and clinics operating for
gain. It must be unalterable by the physician,
and include all that the standard form of pro-
cedure delineates. In addition, there must be
definitely known charges for any additional ex-
aminations, such as x-ray and blood chemistry,
and these must be comparable with the scale of
charge for the entire examination. If such a
plan is to succeed, the patient must be given all
he needs to warrant thoroughness and complete-
ness in examination and diagnosis, but his fi-
nances must be conserved and we must not per-
mit his being mulcted through incidental exam-
inations. There are plenty of good x-ray and
diagnostic laboratories which will be only too
willing to cooperate in this work, and furnish
service at less than standard rates.
(3) Publication of a list of members of the
County Society of the district, indicating those
members willing to give the examination at the
standard fee. The public must be apprised of
the adoption of such a plan, and must know what
physicians are available for examinations. To
avoid any possibility of confusion as to medical
standing, the entire roster of the county society
— which means the roll of men acceptable to the
medical brotherhood — should be published. How-
ever, as plan acceptance is elective with mem-
bers, such published lists should clearly indicate
those men who are willing to give examinations,
as contrasted with men in good standing who
neither subscribe to the form procedure nor the
standard fee. The publication of such lists will
prove of material assistance to the county so-
cieties. The public will be enabled to ascertain
the identity of medically-eligible men. Illegitimate
practitioners will find the going harder, and twi-
light practitioners will be refused the light of
community acceptance. A reference list of com-
petent physicians will be available in emergency.
Physicians will profit individually and as a group,
for an ethical type of advertising is available.
The public will profit vastly from the oppor-
tunity to distinguish the medically acceptable
from those who are not, and through elimination
of the undesirables in medicine.
(4) Publication of the detailed form of pro-
cedure. The public at large does not know what
a’ complete medical examination means. The
average person knows that for a cold his chest
is examined, and for a sore throat his nose and
throat are gone over, but he has seldom if ever
gone to his physician for a complete examination
when he was not sick. This fact doubtless ac-
counts in large measure for the reputation for
completeness and thoroughness acquired by lay-
controlled clinics specializing in health examina-
tions. A patient visiting the office for treatment
of a head cold, or sebaceous cyst of the scalp,
would think it very queer if the doctor tested
the ocular movements and reflexes, took the
height and weight, looked in the ears, tried the
patellar reflexes, and so on. But the same pa-
tient, subsequently taking a routine examination
at a clinic specializing in such examinations,
would doubtless widely advertise the thorough-
ness of the going over he received. He would
often compare critically his experience with his
visits to his own doctor. Such a patient ignores
the truth of the matter — which is, that he never
went to his doctor for a complete examination
when he was not in fact a “patient”. But, if he
had gone to his doctor for a complete examination,
would he have received one? And if he had, how
would he know it to be adequate and thorough.
In my opinion, the public should be acquainted
with what may be expected in a complete exam-
ination. If people know what is due them, the
examining physician must render it to them.
The physician conducts a complete examination,
and the patient is satisfied. If it is not thor-
ough, the patient will know it, and the physician
will suffer in consequence.
The form of procedure must be broadcast, and
copies of the form made available on request. It
will not take the average American citizen long
to know exactly what to expect for his money,
and we 'may be sure that he will see that he gets
it.
In addition to the 4 major component parts
detailed above, there are numerous factors of
less importance which require mention and con-
sideration. I hardly need mention the value of
the plan tc the public in early detection of con-
ditions which are of serious import if neglected.
Likewise, I need hardly detail the value of the
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
457
examinations to the physicians who detect those
defects which require attention and treatment.
But the Medical Society must police its own or-
ganization, or have it policed for them, to insure
the patients against unnecessary and expensive
follow-up treatments hy the occasional commer-
cial and dishonest examiner.
When the examination is concluded the patient
should be given a written report, with notation
of defects which require attention. The detailed
record of the examination is to be held and filed
by the examiner; however, if the patient decides
to take treatment elsewhere, a copy of the com-
plete record of the examination must be for-
warded to the physician treating the patient,
should he request it. This is proper and ethical,
and cannot fail to materially increase confidence
in our efforts along these lines.
In conclusion, I believe the publicity asso-
ciated with this plan will be a strong welding
bond between physician and layman. The pub-
lic is entitled to know the names of competent
physicians willing to give adequate health ex-
aminations for a set fee. The public is also en-
titled to detailed knowledge of the content of
adequate health examinations. The education
along these lines cannot help but make for bet-
ter service to patients and cannot help but make
tire average physician better in respect to detail
and completeness in his work. There is bound
to be an increase in the confidence and respect
of the public toward physicians as a group, for
a move which is so clearly for their betterment.
The County Society may thus become a real fac-
tor in the promotion of public health plans and
in the protection of public health by the endorse-
ment of means of bettering medical practice.
In this paper, I have not discussed in detail
the relationship of physician to patient, advice
for treatment, disposal of examination forms,
reference^ of patient elsewhere, care of laboratory
and x-ray needs, etc. I have rather definite ideas
upon these matters, but the one of prime im-
portance at first is to pass and act upon the value
of the plan itself. When the major issue is decided,
the lesser ones are easily dispatched.
Discussion
This paper was discussed by Drs. Quigley, Nor-
ton, Gordon, D’Acierno, and Waters. A motion
was made and seconded that the president ap-
point a committee to further and carry to a con-
crete conclusion the ideas embodied in Dr. Wa-
ter’s report.
Dr. Merrill A. Sioiney read a paper — “Technic in
Obstetrics”.
Every physician will agree that an obstetrician
may in one sense be skilfull, and yet he may have
disastrous results. He will have a death rate of
1 in 50 from puerperal sepsis, unless he also at-
tains skill in conducting his war against germs.
During the last generation the germs have been
holding their own in the battle. The doctors
have not cut down the death rate from puerperal
sepsis. In many cities a woman takes less
chances of dying from infection if she goes to a
midwife. The latter does not carry on her hands
so many germs of infection as the doctor who is
handling all sorts of cases.
About 15 years ago I read a paper before this
society on the use of iodin in obstetrics. I had
then used it exclusively for 3 or 4 years. After
a continual use of this method for over 15 years,
I am still enthusiastic about it. It has proved its
efficiency. We have delivered in my sanatorium
in 18 years, 1292 women. Only 1 of those pa-
tients died of puerperal sepsis. Before entering
the sanatorium, she had been bleeding from pla-
centa previa for 2 weeks. Many physicians had
examined her. When she was admitted, her
temperature was 102.8°; pulse, 140; Hb., 55%.
A large pack was in the vagina and the lower
uterine segment. She showed all evidence of in-
fection, when admitted. iShe died of general
peritonitis.
In 4 engagement cases, forceps failed. Then
I did cesarean section. These 4 women lived,
and there was no sepsis, showing that iodized
forceps carried no infection into the uterus. This
is the proof I offer that my antiseptic technic is
practically perfect.
I gave up the idea of aseptic technic many years
ago, as I considered it a delusion. The technic
depends on 3%% solution of iodin. At examina-
tion, the vulva and perineum are painted with it;
the dry rubber glove is painted with it. At de-
livery, the vulva and perineum are again painted,
and all instruments are painted with it, I did
use 7% solution of iodin, but occasionally it blis-
tered the skin; the 3%% solution gives no
trouble.
One thorough vaginal examination is my rule.
If it is complete, no other is necessary, until de-
livery is decided upon. Some doctors make many
examinations in the course of long tedious la-
bors. I unreservedly condemn that practice. The
rectal examination is unsatisfactory to me. My
morbidity and mortality rates prove that a va-
ginal examination can be almost perfect. The
patient is put in the lithotomy position on the
examination table; pubic hair is shaved; vulva
and perineum are painted with iodin; a dry rub-
ber glove on the left hand is also painted with
iodin and careful vaginal examination follows.
We delivered almost all patients in bed. We
take only high forceps, cesarean section, or dif-
ficult version cases, to the delivery room. We put
flannel leggings on the patient and place her on
an obstetric pan of my own design. This pan
makes the delivery easy; the legs are in the best
possible position to relax the vaginal outlet. Not
much care is needed to prevent contamination, as
the pelvis is elevated from the bed, and the
drainage drops directly into the pan. If there
is considerable leukorrhea, we use an instilla-
tion of 4% mercurochrome, 15 minutes before the
examination; we use it occasionally during prog-
ress of the labor. The use of the pan prevents
contamination in the third stage. After delivery,
the binder is adjusted, the patient is covered, the
pan is removed, and the bed is dry. There is a
minimum of disturbance to the patient.
My method is simple; it is much easier than
delivery on a table, in ordinary cases; patient
is not excited; relatives are not alarmed; it causes
much less anxiety than taking the patient to a
delivery room; requires a minimum of ether;
and it needs but few assistants.
This technic can just as well be carried out in
the home. Nothing can be simpler; nor more
nearly perfect. I urge the general practitioner
who is handling obstetric cases to make note of
and try this technic. It saves a great deal of
time wasted in boiling gloves and instruments
and waiting for them to cool.
i
458
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
Discussed by Drs. Quigley, Norton, Gordon,
D'Acierno and Waters.
The following applicants having been favor-
ably reported upon by the Board of Censors, were
declared elected: Drs. Solomon Hirsch, William
Yudkoff, and Eugene M. Kiely.
The following new applications were received
and referred to the Board of Censors: Drs. Nich-
olas M. Alter and Lawrence V. Lindroth.
Clinical Society of North Hudson Hospital
J. Africano, M.D., Reporter
The regular monthly meeting of the Clinical So-
ciety was held Tuesday, April 14, with Dr. Hekim-
ian acting as chairman; 47 members and guests
present. Dr. Tannert read the hospital report for
Mai eh 1931: 233 admissions; 238 discharges; 20
deaths (13 under 48 hours), of which 11 were sur-
gical, 5 medical, 2 new-born, 1 urologic, and 1
pediatric.
Dr. Klaus discussed a fatal case of “Mesenteric
Thrombosis writh Gangrene of the Intestines”. The
patient was ill for 3 days with symptoms of intes-
tinal obstruction, especially vomiting, distension
and fever; though the history suggested nothing
to account for obstruction. Small intestine was
found to be gangrenous in segments, with almost
healthy loops in between, for a distance of 15 feet,
while the mesenteric vessels were definitely throm-
bosed; nothing could be done for the patient, and
he expired 18 hours postoperatively.
Dr. Comoro, reported a “Bilateral Detachment of
the Retina”. M. C., white, aged 42, admitted Oc-
tober 13, 1930, with symptoms of well-developed
toxemia of pregnancy and renal insufficiency; had
9 children, and 2 miscarriages; B. P. on admission,
224/156. Right eye showed a beginning choked
disc with edema of the surrounding area; several
small fresh hemorrhages, and detachment of al-
most the entire lower half of the retina, which
ballooned out into the vitreous cavity. Left eye
showed detachment involving both upper and
lower portions of the retina, without damage to
the macula. Vision was limited to perception of
fingers at 2 feet. Tension of both eyes normal or
slightly less.
On October 25, 1930, the edema of both fundi was
more marked; exudative patches larger and more
numerous; bulbar conjunctiva of both eyes edema-
tous and greyish in color. Vision of both eyes
limited to Anger perception.
On October 27 labor was induced by the Voor-
hees’ bag and a dead macerated, male fetus, of 8
months’ gestation, was expelled. On October 30,
the fundi showed marked improvement; detach-
ments in both eyes had receded remarkably, and
the upper detachment of the left eye had dis-
appeared entirely. Choked disc increased however;
there was more tortuosity of the vessels, more
venous congestion, and greater number of exuda-
tive and hemorrhagic spots. Vision improved.
Dr. Selinger. “Multiple Intra-ocular Foreign
Bodies”. E. D., boy, aged 7, playing with detona-
tion caps, caused an explosion which produced the
following results:
Face was peppered with copper particles, left
eye perforated, lens displaced, and traumatic iridec-
tomy was accomplished; the lens was cataractous,
vitreous lost, tension gone, vision limited to light
perception and poor light projection; also detach-
ment of the retina, and retention of 2 foreign
bodies. The right eye, supposedly good, showed
point of entrance of a foreign body at about 5
o’clock position. Examining the fundus, with
pupil dilated, a shiny piece of copper was clearly
visible in the vitreous at about 4 o’clock position.
The question arose as to the best line of procedure
for saving the patient’s vision in the only good
eye.
After consultation it was decided to leave the
right eye and its foreign body alone, and watch it
carefully for the possibility of any reaction;
secondary effects, or sympathetic results. The
vitreous hanging out of the left eye was cut Aush
with the cornea and allowed to recede; otherwise
both eyes were left alone surgically, and medi-
cally they were kept under atropin.
Vision in the right eye is 20/15 with a -j- 1 sphere
combined with a 0.50 cyl. ax. 90°. L. E. vision
limited to light perception and poor light projec-
tion. The everlasting question now arises: “What
will happen to the right eye, with its contained
foreign body?” Time alone will tell.
Dr. Comoro. “Sublingual Cyst; 2 Cases.” H. L.
and A. S., each aged 15, giving vague history of
trauma followed by swelling under the tongue
gradually increasing, and causing difficulty in
swallowing and pressure on the larynx, not as-
sociated with pain or other discomfort. Examina-
tion showed a Arm, cystic, oval tumor, the size of
a small egg, with long diameter anteroposteriorly,
slightly to left of the median line; inferior to the
submaxillary gland and rather freely movable. Un-
der general anesthesia, an incision was made in
the Aoor of the mouth, from before backward, and
with dull dissection the tumor, in each case, was
shelled out intact; wound closed with silk sutures.
Cysts found in the sublingual area are usually
dermoid in character, and are sometimes er-
roneously diagnosed as ranula or sebaceous cysts.
Dermoids are congenital but often do not develop
until late in life. The great majority occur be-
tween the ages of 12 and 25. They are benign
until they encroach upon other organs, when they
become dangerous. Exploratory puncture will
usually make the diagnosis, for aspiration of the
sebaceous contents points either to dermoid or
tliyroglossal cyst, and they cannot be differentiated
clinically; diagnosis depending on pathologic study
of the cyst contents or wall.
Dr. Ash. “Chronic Mastoiditis Complicated by
Brain Abscess.” M. B., female, aged 17, was ad-
mitted October 24, 1930. complaining of chills,
headache, and vertigo; slightly irrational; temper-
ature 99.2° in morning and 104° in evening; pulse,
120-140. Had the usual children’s diseases and a
discharge from both ears at intervals for years.
Present illness began on the morning of October
12, when she awoke with dizziness and vomiting.
These symptoms continued for about a week, then
she developed chills and fever.
Physical examination showed moderate amount
of rigidity of the neck; positive Kernig and Oppen-
heim; knee-jerk absent; pupils regular and re-
acted to light; retinal veins full and tortuous, with
double papilledema; purulent discharge from the
right ear with slight edema over mastoid and mod-
erate amount of tenderness.
Radical mastoid operation revealed choles-
teatoma in the middle ear with unhealthy dura
exposed in the middle and posterior fossas; lateral
sinus was also covered with dark, unhealthy gran-
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
459
illations. Within 24 hr. the fever had disappeared
and the pulse rate dropped to 100. The drowsiness,
headaches and vomiting gradually subsided and in
about 4 weeks following operation the patient was
feeling quite normal. Two weeks later, or 6 weeks
postoperative, fever rose to 101°; the patient be-
came slightly delirious, had some headache, vomit-
ed frequently and had 3 convulsions in 24 hr.
Spinal puncture showed clear fluid and normal
pressure, 24 cells per c.mm. ; slight increase of
globulin and decrease of sugar. Culture negative.
Drawing spinal fluid apparently relieved the intra-
cranial pressure and the patient’s symptoms grad-
ually subsided. The mastoid wound was too small
for the amount of discharge and since the head-
aches and vomiting attacks were returning, it was
decided to complete the radical mastoid operation
by making a flap. The dura was also inspected
and incised. This gave vent to some clear spinal
fluid. The headaches and vomiting ceased and the
patient left the hospital about 1 month later.
Five months following operation the patient
shows a gain of 14 lb; the discharge has lessened,
has no bad odor, and appears to be coming from
a subdural abscess in the posterior fossa.
Dr. Ash. “Pansinusitis Terminating in Menin-
gitis.” W. R., male, aged 13, admitted with con-
siderable sw'elling, edema and tenderness of the
forehead extending into eyelids; intense pain; pro-
fuse purulent discharge from both nostrils and
both ears. Present illness began with grippe 2
weeks before admission. Considerable tenderness,
swelling and edema with fluctuation over the
frontal bone. Entire mucous membrane of the
nose swollen; right eye deviated outward, with
limitation of movement; fields, vision and optic
nerve heads normal. No signs of meningitis. Tem-
perature 103°; P. 110; R. 20. Culture from nose:
Staph, aureus.
A diagnosis of pansinusitis, mainly involving the
right side, was made. The right middle turbinate
was removed and the anterior ethmoid cells open-
ed, which released 2 V2 oz. of thick pus. The open-
ing into the right frontal was enlarged; and also
an opening was made into the right antrum. Thin,
foul-smelling pus escaped from the frontal sinus
and antrum. Incisions IV2 in. long were made
above the inner part of each brow, which gave
vent to 3 oz. pus. It was thought that this would
be sufficient drainage to allow the patient to re-
cover his strength before having a more radical
operation.
There was gradual improvement in condition,
until about a week later, when fluctuation was
noticed at the outer end of the left eyebrow. This
area was incised, with escape of considerable pus.
A left antrotomy was performed and considerable
pus was washed away. The swelling in the mu-
cous membrane of the nose had subsided, nasal
breathing had become quite free and the amount
of pus from the nose and frontal region had les-
sened considerably; but as the frontal tendernesss
disappeared, it spread along the left parietal region
to the occiput. Pain in the head became more
severe. During the next 3 days pulse dropped to
72, became weak and irregular. Projectile vomit-
ing occurred; the patient became drowsy and ex-
pired.
In reviewing this history I am convinced that
the patient was doomed to die from the very be-
ginning, yet a more careful examination of the
central nervous system, e.g., testing of reflexes,
searching for evidences of muscular spasms and
paralysis, record of hearing, examination of the
spinal fluid, a greater exposure of the frontal bone,
etc., would undoubtedly have simplified the diag-
nosis.
Dr. 8. Braunstein. “Case of Trichinosis.” H. H.,
male, aged 19, white, employed on a swill truck
in Secaucus, admitted because of pain in the calves,
thighs and elbows; more severe with the arm ex-
tended. Venereal denied.
He developed pains in the muscles of the lower
extremities and he noticed that his face, eyes and
hands became swollen, so much that he could
hardly open his eyes.
A chain of glands palpable on both sides of the
neck in the postcervical region; fairly firm, dis-
crete, freely movable and not tender. Tenderness
at both elbows and fore-arms; no swelling or red-
ness of joints. Epitrochlear glands palpable and
also the axillary glands. Tenderness over both
calves and thighs; no edema.
Blood count, 5,632,000; W. B. C., 16,600; polys.,
30%. A test for the Bacillus mellitensis was nega-
tive. The Widal showed a partial agglutination
1-40. and 1-80.
The striking symptoms in this case are the
edema of the eyes and face, fever, muscular phe-
nomena, adenopathy, enlarged spleen and heart
murmur. With these findings we considered this
a case of trichinosis with the following to be con-
sidered in the differential diagnosis: Glandular
fever, aleukemic leukemia, typhoid and lues. The
history of eating pork over a long period of time,
the fact that several of his friends with whom he
worked were also taken sick about the same time
with similar symptoms, the swelling of the eyes
and face and the muscular pains all gave evidence
for the diagnosis.
Just 2 days before the patient was discharged
we teased the deltoid muscle with a 28 gauge
needle and were rewarded with a beautiful speci-
men of the trichina on the slide. Later a biopsy
was done and this also showed the trichina on
frozen section.
Dr. Kaplan. “Strangulated Non-descended
Testes.” J. O., aged 32, white, occupation milk-
man ; admitted writh the chief complaint of pain
in the right inguinal region. After an alcoholic
bout, the patient started vomiting, which con-
tinued all the next day. Then experienced a sud-
den sharp, lancinating pain in the right inguinal
region, constant and radiating upward along Pou-
part’s ligament to the iliac crest. The pain be-
came cramplike after a few hours. The next day,
he went to work but was unable to continue be-
cause of another attack of sharp pain.
There was a marked tenderness on palpation
over the right inguinal region, and a mass about
the size of a walnut, not reducible. No impulse on
coughing. Scrotum did not contain any testicles.
The right inguinal canal was opened and the tes-
ticle found edematous and gangrenous with the
spermatic cord twisted upon itself 4-5 times. He
made an uneventful recovery.
Dr. Eckert. “Bilateral Chocolate Ovarian Cysts — ■
Ruptured.” Chocolate cysts of the ovaries are be-
nign cystic formations closely allied to and fre-
quently spoken of as a form of extra-uterine endo-
metriosis. Chief characteristics are either cystic
formations or cavities, frequently bilateral, filled
with a chocolate colored tenacious fluid. According
to Bailey, endometrial tissue finds lodgment on the
ovary and implants itself; then invades the ovarian
460
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
tissue and excavates and proliferates. The pro-
liferated tissue degenerates and this, with the
blood from menstrual activity, results in a pe-
culiar cyst. The diagnosis is very difficult and
generally made at the time of operation, or by
aid of the microscope. It may be easily con-
founded with chronic adnexal disease although the
condition itself is not inflammatory.
Medical Center of Jersey City
Joseph Binder, M.D., Reporter
The regylar monthly meeting of the Medical
Staff was held on Thursday evening, April 9, in
the Out-Patient Department of the Hospital, Dr.
C. B. Kelley presiding. Among those present were:
Drs. O’Hanlon, Binder, Peters, Houghton, Braun-
stein, Hashing, Alter, Perkel, Fineberg, Street,
Scially, Ghee, Cohen, Riese, Rector, Benjamin,
Harter, Christian, Rundlett, Variano, Fellman,
Winter, Perlberg, Macchi, Burke, Sprague, E.
Connell, Borshaw, Siegler, and Freile.
Dr. Charles M. Peters presented 2 cases of
“Tumor qf the Jaws”, both patients over 50 years
of age. The growths were of the upper jaw,
diagnosed adamantinoma and carcinoma. Particu-
lar stress was laid upon a correct diagnosis as a
means of planning a successful surgical procedure
and conserving function and esthetics. Under
radium and x-ray treatment the carcinomatous
mass entirely subsided. The adamantinoma was
treated by complete removal, cutting outside of
the free border with cautery, and previously ligat-
ing the carotid artery.
Dr. Peters also presented different stages of
operative procedure in cleft palate and cleft lip,
emphasizing the importance of operating within 3
months to obtain proper correction of the bones.
At this period the bones are treated in the same
manner as one would a fracture. The early bone
operation corrects to a great extent the lip and
flattened nostril. The lip operation usually fol-
lows in 6 weeks and the soft palate around 18
months, or before speech begins. The mortality
is lowr providing the proper preparation of the in-
fant is carried out. The advice given to parents
to postpone these operations in infancy is de-
plorable.
These cases were discussed by Drs. Braunstein,
Alter and Kelley.
Dr. Rundlett presented 2 cases of “Diphtheria
of the Penis, Following Circumcision”. In the
Journal A. M. A., May 3, 1930, there was a case
of penile diphtheria reported, and it was stated
that only 15 could be found in literature. Generally,
diphtheria of the penis is secondary to some other
diphtheritic lesion in the body; nevertheless, sev-
eral cases have been reported in which the infec-
tion was primary in the genitals. A number of
cases reported in the literature occurred a fewr
days after circumcision. The case cited by the
Journal A. M. A. is the only one which has ever
occurred in the Municipal Contagious Disease
Hospital of Chicago, out of a series of approxi-
mately 14,000 cases of oral diphtheria.
We present a case (by We, I mean Dr. Troost,
who was with me at the time, and to whom much
credit is due) as follows: A 9 months’ old child was
admitted to the Medical Center for circumcision.
Unfortunately, there is no record of a routine ad-
mission ward culture. Baby was operated on, on
January 8, 1930, and infection first suspected on
January 15.
Dr. Emmet Connell saw the child next day and
suspected diphtheria. Culture was sent to the
laboratory and reported negative for diphtheria.
Case re-cultured, both glans and throat, and
the report came back, positive for penis, negative
for throat. I was requested to take him over to
Isolation. He received 10,000 units diphtheria
antitoxin intramuscularly and the glans was
sprayed daily with diphtheria antitoxin. Wet com-
presses of boric acid. There was extreme redness
about, and the whole area of glans covered with
thick grayish-white membrane. On January 19 there
was a sudden rise in temperature, and within a
few hours a sharply defined reddened area ex-
tending well up on the abdomen and down on the
thighs and scrotum. It was not the typical,
brawny red of erysipelas, but it was raised and
indurated.
As this infant had received already a large dose
of diphtheria antitoxin, we hesitated about giving
another serum for the erysipelas. The dressing was
changed to warm magnesium sulph., and there wras
a slight recession up to January 25, when the
area again began to extend. There was involve-
ment of the buttocks, showing a sharply defined
erysipelas with distinct line of demarcation. Ery-
sipelas antitoxin was given (500,000 skin test units,
equal approximately to 10 c.c.) but the lesion con-
tinued and extended, and the child developed
bronchopneumonia. Getting no results from the
erysipelas antitoxin, we switched to the antistrep-
tococcic polyvalent serum, 20 c.c., with gratifying
results, proving that we had a streptococcic ery-
sipelas. Apart from a severe serum rash the little
fellow continued to improve and went home on
February 12 cured.
This was the second case we have had. The
other, a 3 year old boy, was circumcised on De-
cember 17, 1929, and discharged on December 19.
He was re-admitted to the hospital through the
G. U. Clinic 2 days later with what was supposed
to be an infected circumcision. On December 28
child developed high fever, difficult breathing and
swollen cervical glands: apparently very toxic.
Examination revealed that throat was covered
with grayish white membrane. He was given
20,000 units diphtheria antitoxin by the throat
specialist who also requested isolation. The penis
was sprayed twice daily with antitoxin and kept
moist with warm Wright’s solution. Laboratory
reports were positive for nose, throat and penis,
until January 20, when we got our first negative.
On January 24 temperature rose to 103°. Examina-
tion of chest revealed bronchovesicular breathing
in right median line, with limitation of breath
sounds pointing to a bronchopneumonia. Child ex-
pired on January 26.
Cases were discussed by Drs. E. Connell and
Siegler.
Drs. Sprague and Doran presented 3 cases of
“Paget’s Disease”.
Case 1. Female, broke left leg 10 years ago. This
united well, but patient still complains of pain,
with bowing of left leg. Later on there was
bowing of the right leg. About 8 years ago she
noted that her hat did not fit head and also that
her right shoulder bothered her. Paget’s disease
was suspected, and diagnosis confirmed by x-rays.
Case 2. Male, with history of disease of 12 years’
duration. The tibia and fibula showed definite
changes with bowing which is so characteristic of
the disease.
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
461
Case 3. Female, admitted with fracture of femur.
Radiograph showed evidence of Paget’s disease, in
this case not extensive. Patient was allowed up
after being in bed for 10 weeks. In spite of the
fact that there was a large amount of callus
thrown out at the site of fracture, this patient sus-
tained a spontaneous fracture of the same femur
3 in. above site of previous fracture.
Dr. Benjamin presented 4 cases of “Pott’s Dis-
ease in Adults”, because of the relative rarity
of the disease in the adult; 10% of cases. There
were 2 male and 2 female patients, ages 27, 46, 35,
and 17 respectively, the average age of onset being-
over 20 years. The chief complaint was pain,
acute and severe in 2, and gradual in the others.
The girl of 17 had pain for 3 months. The man of
46 complained of paralysis.
In contrast. Dr. Benjamin also showed 3 cases
of ‘traumatic spondylitis” (Kummel’s disease).
In Pott’s disease, x-rays early show body then
cartilage destruction, with later increase in car-
tilage width, and perivertebral thickening, show-
ing as spindle-shaped shadow of thickened soft
parts. If this breaks down abscess results. In
the adult, acute onset with pain is more common,
and 10% of these show paralysis due to inflam-
matory mass, bony encroachment, or pachymen-
ingitis.
Dr. Harter presented a case of “Recurrent Car-
cinoma of the Rectum”. Female, first seen in 1928,
with mass in rectum,, protruding on excetion.
Biopsy showed odenocarcinorna. Hemoglobin was
50% and patient was tranfused with 1000 c.c.
whole blood. Tumor then removed by actual cau-
tery. Stricture of rectum resulted. In April,
1929, treatment was with radium 1630 m.c. am-
peres. Patient not seen until November, 1930,
when she complained of bleeding from rectum.
Digital examination elicited a tumor, the size of
small lemon, on anterior wall of the rectum. Op-
eration of colostomy. There was no evidence of
metastasis. The tumor decreased in size to small
hazel nut size. It was then removed by resecting
the rectum. Proximal end cauterized and sutured,
and levator ani closed over. Patient is draining-
through colostomy wound.
Discussed by Dr. W. Friele.
Dr. Braunstein showed specimen of autopsied
rabbit used in performing the Ascheim-Zondek
test for pregnancy. Instead of using a series of
immature mice, he used a young rabbit 10-12
weeks’ old, and injected 8 c.c. urine. The ovaries
of this rabbit showed hemorrhage indicating that
the patient from whom the urine was taken is
pregnant.
Dr. Hutchinson reported the autopsy findings of
a case of “Ulcerative Staphylococcus Aureus
Endocarditis” in which source of infection was
not determined.
Bayonne Hospital Clinical Conference
Maurice Shapiro, M.D., Secretary
The regular meeting of the Clinical Confer-
ence of Bayonne Hospital was held Monday even-
ing, April 6, with Dr. Brooke acting as Chairman
and Dr. Shapiro as Secretary.
Dr. Finger reported from the service of Dr.
Brooke 5 cases of breast tumors, in which the
microscopic diagnosis from a quickly frozen sec-
tion was of immediate aid to the surgeon in de-
ciding upon radical or conservative operation.
Case 1. Female, aged 50, admitted March 3, with
history of noticing 2 weeks previously a lump in
her right breast about the size of a walnut; not
painful and had not enlarged since then. Sister
died of carcinoma. Mass easily palpable just be-
low nipple of right breast; no fixation; no aden-
opathy in right axilla. A semilunar incision was
made on either side of the nipple, at the edge
of the gland and the tumor was gradually dis-
sected out. The skin was closed with silk worm
and clips.
Report of the specimen sent to laboratory
showed a scirrhus carcinoma present, about 1.5
ctm. in diameter, without any lymph-nodes.
Case 2. Female, aged 31, admitted March 22.
Trouble began 4 weeks previously, when she
noticed a painless lump in her right breast. She
consulted a physician who advised its removal.
A biopsy was done and the section immediately
examined by frozen section method. After re-
port was obtained from the laboratory the en-
tire breast was removed and wound closed with
silk worm and clips. Specimen was quite cellu-
lar, with moderate amount of connective tissue
in its meshes. The nodules were not encap-
sulated and tumor tissue was present in the
lymphatics. Diagnosis: Adenocarcinoma of
breast. This case is interesting because of the
patient’s age. According to Babcock, carcinoma
of the breqst in women under 35 years of age is
unusual. -
Case 3. Female, aged 51, admitted March 22.
About 5 months previously patient noticed a re-
traction of the left nipple and a lump in the
breast. Sometime later she began to suffer from
shooting pains down the left arm and progres-
sive swellings in left axilla. She consulted a
physician, who sent her to The Memorial Hos-
pital, in New York, for deep x-ray therapy. She
received 5 treatments and was advised to have
an operation. The skin in the region of the left
breast was discolored from x-ray therapy. The
breast was enlarged and the nipple retracted;
firmer than normal and there was a nodular
mass in the left axilla. Large elliptical incisions
were made extending from axilla to a point well
below the left breast, the underlying fascia and
part of the pectoralis major were removed. The
axilla was explored and some fascia and lymph-
nodules removed. The wound was closed with
silk worm gut and clips.
Report showed a very scirrhous breast with
numerous typical and irregular cells scattered
about. Tumor tissue had invaded the surround-
ing structures. Being an advanced stage of the
jdisease, recovery, according to - statistics, is less
than 20% chance.
Case If. Male, aged 30, admitted March 5. Trouble
began about 9 years before admission. He was
rowing for an athletic club and received a se-
vere blow with an oar, in the left breast. Two
years after the accident, noticed a lump in the
same breast, which was becoming progressively
larger until it had finally reached the size of a
lemon. The breast had been sore ever since the
accident, but had never given much trouble. Re-
moval was advised.
An oval incision was made over the mass and
tumor removed with surrounding fatty tissue.
Report was a fibro-adenoma without any evi-
dence of metastasis.
Case 5. Female, aged 29, admitted December 3.
About 8 years ago she noticed a lump in her
right breast which gradually increased in size
462
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
until it reached the size of a lemon; a hard,
freely mo\able lobulated mass. Incision made
through skin, superficial fascia and gland sub-
stance intervening between fascia and outer wall
of tumor. Entire growth was excised, and cavity
approximated by deep sutures followed by clos-
ure of superficial wound.
Tumor consisted of 9 small firm masses which
were well encapsulated. Microscopically there
was atrophy of the glandular tissue. Intracanal-
icular fibro-adenoma.
Dr. Antapol stated that diagnosis by frozen sec-
tion, if the pathologist has been notified in ad-
vance and can have things prepared in time, can
be made in 5 minutes. Experience has shown
that diagnosis made in the microscopic stage re-
sults in the highest percentage of cures. He
also stated that after operation on a malignant
case, there is a metastasis of the growth by a
milking or suction action of the lymph channels
and that, therefore, it is necessary to institute
x-ray or radium treatment immediately. These
conclusions have been verified by laboratory ex-
periments on animals. He stated that there are
3 reasons for diagnosis by frozen section. (1)
The question whether the operation shall be
radical or conservative. (2) Clinicians realize
that the microscopic stage of the disease should
be recognized. (3) To differentiate between be-
nign and malignant tumors.
Dr. Brooke suggested that all cases of malig-
nancy where the diagnosis is made from clinical
evidence, should have a chest x-ray plate made
in order to see if there is any metastasis into the
lungs. He believes that if cases show metastasis
they should not be operated on, as it only has-
tens death.
Dr. Murray reported the very interesting case
of a woman about 32 years of age who began
vomiting with extreme pain in the abdomen, af-
ter previously complaining of a dysmenorrhea.
Dr. Brooke saw this patient in consultation and
thought there was ovarian trouble. At opera-
tion a tuberculous peritonitis was found and
tuberculosis of the appendix, ovaries and tubes.
The patient is now getting better.
Dr. Brooke suggested that one should always
bear in mind tuberculosis when there are ovarian
and tubal symptoms. He thinks that panhyster-
ectomy is indicated in this case because tuber-
culous cases are always over-sexed, and the re-
sulting artificial menopause reduces sex desires
and helps toward improvement.
Dr. Feinberg reported on the use of antitoxin
in several cases of erysipelas. Two cases were
confined solely to the face and the other ex-
tended to the chest and other parts of the body.
Treatment used, 5000 units of erysipelas anti-
toxin in each case, plus the local treatment of
magnesium sulphate, glycerin dressings and boric
acid applications.
In 2 cases temperature was normal after 48
hours following administration of the serum,
while in the more extensive case the symptoms
cleared up and condition abated after the fifth
day. Local use of immune serum, after the
methods of Rivers and Tillet, showed that the
infiltration of skin with normal or immune serum
renders the areas thus treated quite refractory to
infection with hemolytic streptococci. In most
cases it is found that the process extends to
the infiltrated area and then stops. In Bellevue
Hospital, New York, the largest erysipelas ser-
vice in the world, the antitoxin treatment is em-
ployed to" the exclusion of all other methods.
HUNTERDON COUNTY
Barclay S. Fuhrmann, M.D., Reporter
The Hunterdon County Medical Society met
at Flemington, April 21, at 10.30 a. m. The fol-
lowing members and visitors were present: Drs.
A. H. Coleman, M. H. Leaver, Francis Apgar, E.
F. Purcell, L. C. Williams, G. B. Tompkins, W.
E. McCorkle, E. W. Closson, George Henry, B.
S. Fuhrmann, F. G. Scammell and H. O. Reik.
In the absence of the president, the meeting
was called to order by Dr. Coleman.
After transacting the usual routine business,
and hearing a report of the treasurer which
showed the society’s finances to be in good con-
dition, the president called on Dr. Ernest F. Pur-
cell, of Trenton, to read a paper on “Potter’s
Version’’. Dr. Purcell traced the application of
“version’’ from its inception years ago, to the
present day and showed the changes that had
been brought about in the mechanics of the
operation. The paper was very beautifully illus-
trated with drawings and, at the close, by show-
ing a "clinical movie” of actual cases, which
illustrated better than words the actual opera-
tions. The clear and concise manner in which
Dr. Purcell presented his subject was much ap-
preciated.
After some discussion of the general opera-
tive procedures in obstetrics, the meeting ad-
journed and we were served one of the famous
chicken and waffle dinners by the Union Hotel.
MERCER COUNTY
A. Dunbar Hutchinson, M.D., Reporter
The Mercer County Medical Society met in the
Carteret Club on the evening of April 8, with
Dr. Swern presiding.
The regular order of business was suspended,
and the moving picture, “Spinal Anesthesia”, ex-
hibited.
The application of Dr. Gerold H. Miller was
read and referred tc membership committee.
A communication relative to the parking prob-
lem was referred to a committee, with power to
confer with the City Commissioners.
The subject of contract practice again appeared
on the floor, and following a lengthy discussion,
the President appointed Drs. Samuel Sica, C. H.
Mitchell, E. F. Purcell, A. D. Hutchinson and G.
A. Corio, as a Committee to investigate the sub-
ject and report to the society.
Dr. C. H. Mitchell was elected a member of
the Board of Censors, to fill the vacancy occa-
sioned by the death of Dr. Charles J. Craythorn.
Following discussion on the subject of suit-
able quarters for the holding of meetings, the
society having outgrown the present facilities,
Drs. Schildkraut, Scammell and Sica were ap-
pointed to obtain information relative to the pos-
sibilities of making a change.
The society mourns the loss, through death, of
several of its members, who, by their active par-
ticipation in the affairs of the society, promul-
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
463-
gated the high ideals for which the society
stands, and through their wise counsel, temperate
attitude and broad vision advanced the organiza-
tion of the profession in the welfare of the com-
munity in which they labored: Dr. Raymond S.
Seibert died February 23; Dr. William M. Strat-
ton on March 23; Dr. Charles J. Craythorn, March
28, and Dr. Walter F. Madden, April 13, 1931.
MIDDLESEX COUNTY
Samuel G. Berkow, M.D., Reporter
April meeting was held at Middlesex General
Hospital, New Brunswick, April 22, at 9 p. m.
The scientific program consisted of a paper on
“Hay-Fever”, by Dr. Thommen, of New York
City, and discussed by Dr. Leonard, Director of
Squibb’s Immunogen Laboratories, in New Bruns-
wick.
Dr. Thommen, an outstanding authority on
problems of allergy, presented his subject con-
cisely but with an amazing amount of detail and
the subject seemed to expand in scope under his
capable elaboration; he vivified the subject. He
developed 5 postulates which must be satisfied
for a plant to be considered as an important
cause of hay-fever. By means of lantern slides
he illustrated these postulates, showing the plants
that pollinate and whose pollen contains an irri-
tant capable of causing symptoms of hay-fever;
the importance of wind-born pollen in contrast
to pollen carried by insects; the smaller pollens,
capable of being carried long distances, as op-
posed to those greater than 5 0 millimicrons in
diameter; the quantity of pollen in various plants
satisfying the previous requirements; and those
plants having a large geographic distribution.
He then discussed the treatment of hay-fever by
means of subcutaneous injection of graded doses
of the irritant, and emphasized the danger of in-
jecting even minute quantities into hypersensi-
tive patients, whom he graded into 4 groups.
Dr. Leonard discussed the paper and called
attention to 2 variations from the usual pre-
seasonal treatment. One, which he termed the
English method or “hurry-up” treatment, in
which the patient is confined to bed, preferably
in a hospital, and given graded doses at very
short intervals, completing the treatment in 24
to 48 hours; the other consisting of injections
given to hypersensitive patients at monthly in-
tervals following the preseasonal treatment.
Dr. F. G. Scammell, of Trenton, Councilor of
the Third District, who visited the meeting, re-
lated his own experience with hay-fever and in-
quired as to the surgical treatment of local con-
ditions in the nasal and oral cavities.
A committee was appointed to draw up resolu-
tions expressing sympathy of the society, to be
sent to the families of Dr. Ellis, of Metuchen,
and Dr. Gruessner, of New Brunswick, recently
deceased. Both served their respective com-
munities faithfully and well, and were loyal mem-
bers of the County Society.
A Committee on Public Health and Public Re-
lations was appointed. Dr. Johnson spoke of the
child health conference to be held shortly and
asked for cooperation of the society in this im-
portant state endeavor. The newly formed com-
mittees were instructed to present a plan for
such cooperation.
The subject of by-laws governing the County
Society came up for discussion, and a committee
was appointed to revise the present constitution.
MONMOUTH COUNTY
William Van Oehsen, M.D., Reporter
The monthly meeting of the Monmouth County
Medical Society was held at the Garfield-Grant
Hotel, Long Branch, Wednesday evening, March
25, with Dr. William K. Campbell presiding.
Minutes of the previous meeting were read and
accepted.
A letter was read from E. Donald Sterner,
State Senator, promising his support in opposition
to Senate Bill No. 155. Dr. H. Brown, of Free-
hold, moved that a letter of thanks be sent to
Mr. Sterner ; seconded by Dr. Slocum, and carried.
Dr. H. Brown, of Freehold, reported that the
old minute book had been bound. It was voted
that the cost of binding the minute book ($5) be
paid.
Drs. William Matthews, Frank Niemtzow,
George S. Reynolds and Morris Woronoff were
elected to membership.
Dr. Campbell announced that the Woman’s
Auxiliary is to hold a meeting on April 7, and
urged members to assist in promoting attendance.
An extremely interesting talk was given by Dr.
Byron Blaisdell on “Urologic Conditions’’.
A buffet lunch was served.
OCEAN COUNTY
Eugene G. Herbener, M.D., Reporter
The Spring Meeting of the Ocean County Medi-
cal Society was held February 24 at Murray’s Log
Cabin, Lakewood, with Dr. Adolph Towbin presid-
ing. The following members were present: Drs.
Adolph Towbin, Abraham Goldstein, Alfred Wood-
house, Frank Brouwer, V. M. Disbrow, Harold
Disbrow, Robert Buermann, Herbert Willis, J.
Hilliard,’ Frank Denniston and Eugene Herbener.
Applications for memberships were referred to
the Committee on Membership. The President
appointed Dr. E. G. Herbener, Reporter, to fill the
vacancy caused by the death of our fellow mem-
ber, Dr. Geo. W. Lawrence. A committee consisting
of Drs. Frank Brouwer and E. G. Herbener was
appointed to draw up resolutions on the death of
Dr. Lawrence. (See Obituary Section, this Journal),
The guest speaker of the . evening was Dr.
George N. J. Sommer, President of the State So-
ciety, who spoke on the benefits to be derived by
members attending their County, State and A. M.
A. meetings, which tend to create a better fellow-
ship among the members. He touched on “State
Medicine”, the New Jersey Workman’s Compen-
sation Law, and made some complimentary re-
marks about the Woman’s Auxiliary to the Medi-
cal Society. He also expressed his opinion freely
on matters concerning the county societies, as it
has been his pleasure to visit each of the County
Societies during the past year.
PASSAIC COUNTY
Wayne W. Hall, M.D., Reporter
The regular meeting of the Passaic County
Medical Society was held at the Health Center,
Paterson, April 9, at 9 p. m. Dr. Carlisle pre-
464
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
sided. The minutes of the March meeting were
approved as read.
The application of Dr. Francis Palmer, of 2 7
Monroe Street, Passaic, was received and referred
to the Board of Censors.
The paper of the evening was presented by Dr.
William C. White, Attending Surgeon at Roose-
velt Hospital, New York City, on the “Diagnosis
and Treatment of Breast Conditions’’, and was
illustrated by lantern slides and moving pictures.
Considerable discussion was carried on by Drs.
Leon De Yoe, Thomas Dingman, William Spick-
ers and David Polow. It was stressed that in
chronic cystic mastitis, pain is of little diagnostic
value. The condition is likely benign if lumps
are multiple. In lymph obstruction, the Con-
dolian operation is a failure because the scar is
too near the arm pit and all patients have some
postoperative edema.
Theoretically the ideal thing to do is to block
off lymph by x-rays. One month is required for
proper effect in this treatment. As to infection
in the breast after this procedure, it does not
favorably influence the result.
Simple mastectomy was conceded the indica-
tion in the ordinary bleeding nipple. Propa-
ganda, it was felt, influences procedure, but if a
small lump is found it should be removed.
Multiple cystic mastitis warrants simple mas-
tectomy, as there is more irritation from numer-
ous scars than from simple mastectomy. Dr.
White also stated that in 20% of cases with the
Halsted incision, skin graft is done, the arm be-
ing placed in abduction 3 to 4 days after opera-
tion to prevent edema.
SALEM COUNTY
William H. James, M.D., Reporter
The Salem County Medical Society met at the
Memorial Hospital, in Salem, on Wednesday,
April 8, at 2 p. m. The meeting was called to
order by Dr. Frank Perry. The minutes of the
last meeting were read and approved.
The speaker of the afternoon was Dr. B. L.
Fleming, of Jefferson Medical College. His sub-
ject: “Diagnosis of Acute Abdominal Lesions’’.
He gave a very interesting talk about the dif-
ferent abdominal lesions, such as appendicitis,
duodenal ulcer, and peritonitis.
This paper was very ably discussed by Dr.
George N. J. Sommer, President of the New
Jersey State Medical Society, who went into de-
tails, as did some of the other members of the
society.
Dr. Morrison, Secretary of the State Society,
read a paper on “State Medicine"; and Dr. Reik,
gave one of his usual interesting talks.
Dr. Edward R. Prigger, of Pennsgrove, was
elected a member of the society.
The next meeting will be held at the Country
Club where we have our famous planked shad
dinners about the middle of May.
SOMERSET COUNTY
J L. Young, M.D., Reporter
The bimonthly meeting of the Somerset County
Medical Society was held at the Nurses’ Home
of Somerset Hospital, on April 9, Dr. E. G. Brit-
tain presiding.
The meeting was held in the evening for the
first time in many years to see if it would in-
crease attendance. There was an unusually
large attendance; so a motion was made and
passed that the next meeting be held in the even-
ing at the same place.
In the absence of the chairman of the com-
mittee on collection of fees for compensation
work, the secretary read the report of the com-
mittee. Motion made and passed that the sec-
retary have copies of report printed and mailed
to each member of society.
Dr. Avidan, of the referee’s court, read an in-
teresting paper on “Methods of Collection of
Compensation Bills”.
The meeting was also attended by Dr. George
N. J. Sommer, President of the Medical Society
of New Jersey, and Dr. F. G. Scammell, Councilor
for the Third District; brief talks were made by
these visitors.
Dr. Henry O. Reik, Editor of the Journal of
the Medical Society of New Jersey, and Dr. J.
Bennett Morrison, Secretary of the New Jersey
State Medical Society, were also present and
made short addresses.
UNION COUNTY
Russell A. Shirrefs, M.D., Reporter.
About SO members attended the regular quar-
terly meeting of the society at the Elizabeth Gen-
eral Hospital on the evening of April 8. Dr. M.
Vinciguerra, who presided, introduced the guest
speaker. Dr. Herman O. Mosenthal, Professor of
Internal Medicine at the New lrork Post-Gradu-
ate School. Speaking eloquently, without manu-
script, Dr. Mosenthal lectured on “The Diagnosis
of Bright’s Disease”, and explained in detail the
pathology of the nephritic kidney, impaired renal
function, edema, anemia, hypertension and uremia;
carefully considering the significance and inter-
relation of the above symptoms. Discussion was
opened by Dr. H. R. Livengood, who was followed
by Drs. Wilson, Stern, Banker. Shirrefs and
others, who asked questions which Dr. Mosenthal
answered.
One resignation was accepted on account of re-
moval from the state; 5 were proposed for mem-
bership, to be voted on at the next meeting; the
following were elected : Drs. Frederick Hnat,
George Ladas, Charles Ferguson, all of Elizabeth;
and Gordon A. Stephenson, of Summit.
An enjoyable collation served by courtesy of the
Hospital was followed by a pleasant social hour.
Summit Medical Society
William J. Lamson, Secretary
The regular monthly meeting of the Summit
Medical Society was held at Wallace Pines on
Tuesday, March 24, with President Smalley in the
chair, and Dr. Krauss entertaining. There were
21 members and 6 guests present. The minutes
were read and approved.
Dr. Dengler announced that the Board of Health
was using a diagnostic test for whooping-cough,
by means of the injection of a serum, and hoped
that the members of the society would send sus-
pected cases to him for trial of the test.
May, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
465
The paper of the evening was read by Dr. Ivrauss
on “Medical Economics from the Practitioner’s
Standpoint”. Very few enter the practice of medi-
cine as a means of amassing wealth. The rewards
of a professional career are: interest in the work
itself; the opportunity to know human nature
thoroughly; and the satisfaction of a useful life.
But a physician has a right to live as well as
his ability warrants, and to provide the usual com-
forts and luxuries for his family. Many factors
militate against great financial returns. Prepara-
tion for his lifework is long, tedious, and ex-
pensive. His office equipment and overhead ex-
penses are large if they are to be adequate. Va-
cations or illness are a dead loss. Public health
activities of all sorts are continually limiting his
field of action. Free clinics are abused by those
able to pay. Quacks and charlatans still further
attract the ignorant or gullible public. Much char-
ity work is expected of the doctor, and worthy
charity is cheerfully done.
Sound medical economics can help the prac-
titioner to a better living. Dr. Krauss made many
useful suggestions along this line. A sliding scale of
varying charges, proportional to a patient’s finan-
cial standing and the skill and experience re-
quired, is not only warranted but should be care-
fully established. Telephone calls for advice
should be charged for. Night calls should cost
the patient double the amount of a day call. When
more than one patient is treated in the same
house, an extra fee should be expected. Evening
office hours are illogical and often unnecessary;
no other profession holds them, and calls made
at such hours should be at a higher rate. Much
can be done by the physician in training his pa-
tients to be more considerate of his time.
Many other valuable suggestions as to the
economic • betterment of the practitioner were
made.
The paper was so thoughtfully prepared and
presented that there was no adverse discussion.
Obituaries
DEMAREST, Frederick F. C., until recently
dean cf Passaic physicians, died on Saturday
evening, March 28, at his home, 49 Willard Place,
Rutherford, after a stroke of paralysis in his
seventy-fifth year.
He was a resident of Rutherford from 1870 un-
til a few years ago, and a practicing physician
there since 189 9. On Friday he was out in his
car as usual, but on Saturday morning he spoke
of being ill.
Dr. Demarest was born in Bound Brook on
June 23, 1856. He was the son of the Rev. Will-
iam Demarest, a Dutch Reformed clergyman,
who was a native of New York, and Sarah Eliza-
beth Cornell Demarest, a descendo.nt of the
Freylinghuysen family of New Jersey. He was
graduated from Columbia Grammar School and
from Bellevue Hospital Medical College, New
YTork. Fie was a member at the latter of the
“blizzard class’’ of 1888.
He was a member of the American Laryngological,
Rhinological and Otological Society and of the
American Board of Otolaryngology, besides the
American Medical Association and the Passaic
City Medical Society. He was noted for his in-
vention of several surgical instruments, the most
notable of which is the Demarest tonsillotome.
Resolutions Adopted by the Ocean County
Medical Society
“WHEREAS it has pleased Almighty Provi-
dence to call by death from our professional
circle, Dr. George W. Lawrence, a member of the
society for 24 years,
BE IT RESOLVED that we hereby give expres-
sion of our sorrow at his departure, and do honor
to his memory.
Dr. George Washington Lawrence was a gradu-
ate of the Y'ale Medical College and Chief of Staff
of the Paul Kimball Hospital, Lakewood, N. J.
He died at his home in Lakewood, of a stroke of
apoplexy, while he was recovering from a 6 weeks’
illness from toxic poisoning.
Dr. George W. Lawrence
Dr. Lawrence, who was 6-1. years old, was a
former President of the Ocean County Medical So-
ciety and was nationally known in medical circles.
He was considered dean of surgeons in this part
of the state and was also well known in business
circles, having been Vice-President of the Lake-
wood Trust Company and of the First National
Bank of Lakewood. He was Founder and Presi-
dent of the Ocean County Building and Loan
Association. During the World War he was a
Major in the New Jersey State Militia and di-
rected the medical work, following explosion of
the Gillespie Ammunition Plant, at Morgan, N. .1..
when South Amboy and Perth Amboy were de-
vastated.
He was born at Roxbury, New Hampshire, on
April 2, 1869, and has lived in Lakewood 24 years.
His wife died 7 years ago. Two daughters, Mrs.
Walter Brown, of Lakewood, and Mrs. Russell
Scott, of Plainfield, N. J., survive. He was a
member of several lodges, including the Lakewood
466
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
May, 1931
Masonic Lodge and of Saloani Temple, I. A. A.
O. M., of Newark, N. J., also a member of the
Lakewood Rotary Club and Surgeon for the Cen-
tral Railroad of New Jersey for many years.
Frank Brouwer, M.D.,
Eugene G. Herbener, M.D.,
Committee on Resolutions.
OSMLTN, Louis Cook, of Hackettstown, died at
the Dover General Hospital, Monday, March 30,
1931, after a brief illness with multiple abscesses
of the spleen.
He was 66 years of age, and had been practicing
medicine in Hackettstown since his graduation
from College of Physicians and Surgeons, of New
York City, with the exception of 3 years practice
in Newark.
Dr. Louis Cook Osmun
Dr. Osmun was born in Mendham Township
and was the only son of the late Edward and
Ruth Menagh Osmun.
He was chosen as head of the hospital during
the small-pox epidemic in 1901. He was recognized
and held offices in both the Warren County and
New Jersey Medical Societies, being a Trustee of
the latter at the time of his death. Besides this
he was a Director of the Dover General Hospital
and a member of the visiting staff. He was a
member of the Methodist Episcopal Church, Dover
Lodge of Elks, Monitor Council, Jr. O. TT. A. M.,
and a charter member of the Hackettstown Club.
MADDEN, Walter, 324 South Broad Street,
Trenton, died at his home, April 12, in his 58th
year, of cerebral hemorrhage.
Dr. Madden was born in Tuckahoe, N. J., July
10, 1873, the son of Thomas Madden. His ances-
tors came to this country from Scotland and
settled in New Jersey. His great grandfather,
Hosea Madden, operated in South Jersey a glass
works, which was the first of its kind in America.
Products of the factory were known in all parts
of the world. At the death of the founder, the
business was continued by his son, Hosea, Jr.,
who took an active part in South Jersey politics.
On his mother's side, Dr. Madden was a des-
cendant of the old Steelman family, of Pennsyl-
vania.
The Madden family came to Trenton in 1875.
Dr. Madden received his education in the public
schools and the Rider Moore Business College,
and then studied medicine under the late Dr.
William Rice. He attended Jefferson Medical
College for a time and was graduated from the
College of Physicians and Surgeons, Baltimore,
in 1897.
In politics Dr. Madden met with a success that
would have turned the head of a man less bal-
anced. He was elected to Common Council from
the Third Ward in 1904, and in 1906 was re-
elected by an increased majority. He also served
2 terms as city physician and in 1908 was the
unanimous choice of the Democratic party for
mayor. After a close race, he emerged as vic-
tor over John E. Gill, Republican, by a majority
of 889 votes, and was later reelected by a very
large majority.
In 19 00 Dr. Madden married Miss Minnie
Metzler, daughter of Andrew Metzler. The form-
er mayor was a member of Mercer Lodge, No. 50,
F. .st A. M.; Trenton Consistory, Scottish Rite;
Crescent Temple, A. A. O. N. M. S.; Royal Order
of Jesters; Tall Cedars of Lebanon; Trenton
Lodge, No. 105, B. P. O. E.; Trenton Lodge, No.
164, L. O. O. M.; South Trenton Encampment, I.
O. O. F.; Mercer Circle, No. 40, B. of A.; Mercer
County Medical Society, and the American Medi-
cal Association.
SCOTT, George, died at his residence 9 S„
Pennsylvania Avenue, Atlantic City, Friday March
27, 1931, after an illness of several months.
Dr. Scott came to this city from New Y"ork in
1903 and had practiced here since that year. He
was 80 years old. Born in Illinois, he graduated
from ML Union College, Ohio, and from Bellevue
Medical College, New York, in 1871. He practiced
in New York prior to coming to Atlantic City.
WEBSTER. D. King, died at his home in Lees-
burg, N. J., at the age of 52, after an illness of 2
weeks with pneumonia.
Dr. Webster is survived by a widow, Mrs. Janice
Lee Webster. His stepmother, Mrs. Amelia Web-
ster, is living in Philadelphia. His own mother,
Mrs. Ella Webster, died when he was a child and
his father, Daniel Webster, died several years
ago. Dr. Webster was born in Delmont and was
graduated from the University of Pennsylvania
Medical School. He opened an office in South
Seaville and later located in Cape May Court
House with Dr. Dix. He spent several years in
Kansas prior to 1912, when he came to Leesburg,
where he entered into a partnership with Dr.
George S. Spence which lasted until the World
War, when Dr. Spence sold his share and enlisted.
Dr. Webster was a member of the Cumberland
County Medical Society and a member of Neptune
Lodge, F. and A. M., of Mauricetown. He was
medical examiner for the public schools of Maur-
ice River Township.
467
Journal of The Medical Society of New J ersey
Under the Direction
of the Committee on Publication
Vol. XXVIII., No. 6 ORANGE, N. J„ JUNE, 1931
Subscription, $3.00 per Year
Single Copies, 30 Cents
ALCOHOLIC PSEUDO-PELLAGRA; RE-
PORT OF CASES, WITH NOTATIONS
ON THE ETIOLOGY
N. B. Heller, M.D.,
Newark, N. J.
During the hot summer months we have an
opportunity of observing a number of derma-
toses at the Newark City Hospital and Dis-
pensary all of them presenting certain fea-
tures in common. This has been previously
described by other workers as alcoholic
pseudo-pellagra. A short history of some of
the cases will bring out the salient features.
Case 1. C. P., 39 yr. old, laborer, born in
the United States, was admitted to the hospi-
tal with the following history: Out of work
for the past 3 months, and his diet consisted
of coffee, cake, and an occasional frankfurter;
no fresh meat, vegetables nor fruit during the
entire period. For the past 2 weeks has been
using the average of a quart of poor gin daily,
which caused a persistently upset stomach and
loss of appetite. During the last few days,
when the weather was hot, he slept out in the
park. The last time, asleep with arms out-
stretched, he awoke with a burning pain in
the hands and they were red and covered with
blisters.
Physical examination : Poorly nourished,
anemic, with dark pigmentation of the face
and neck. Speech slightly incoherent, but no
other mental symptoms ; a slight tremor of the
hands. The dorsal aspect of both hands ery-
thematous, infiltrated, covered by a finely
lamellated scaling; a few flaccid bullae and
where they had ruptured the areas were cover-
ed by thin crusts ; in between, there are small
islands of dark-brown pigmentation and dry
atrophy. These changes are sharply demar-
cated and confined symmetrically to both
hands arid lower third of fore-arms.
Laboratory findings were entirely negative,
except for a trace of albumin in the urine and
an occasional cylindroid cell.
Under a generous mixed diet rich in fresh
vegetables and meat he made a speedy re-
covery.
Case 2. L. J., 42 yr. old, laborer, native of
Italy, admitted with the following history :
Out of work for 4 months ; diet very irre-
gular and of poor quality. For the past 3
weeks slept outdoors and used cheap alcohol
freely. During the last heat spell, while sleep-
ing in the park, noticed swelling of both hands
associated with a burning pain and marked
redness.
Physical examination : Markedly under-
nourished; anemic ; an anxious look in his
face; tongue swollen and dark-red. Both
hands and up to the lower' third of the fore-
arms symmetrical dark red swelling, with
marked pigmentation, fine lamellar scaling
with a few scabs where the skin denudation
was deep.
Laboratory findings showed FIbg. 65% ;.
otherwise negative.
Patient made a complete recovery on a gen-
erous mixed diet.
Case 3. A. C., 39 yr. old, housewife, native
of Italy, admitted to the hospital with a nega-
tive family as well as personal history. Has
always been in good health. Gave birth to 8
children ; all living and healthy. Husband has
468
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1031
Case No. 1
Case No. 2
June. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
469
been out of work for some time. During the
past few months diet consisted of starchy
food, mainly spaghetti served in different
ways. W ith this there was an abundant sup-
ply of home made wine. They occasionally
had some milk and eggs, but the children got
most of that. She does not remember eating
any fresh meat, fruit nor vegetables during
the entire period.
During the hot weather she has been sitting
in the yard with sleeves rolled up, thus ex-
posing arms to the direct sun. On one oc-
cation she had a sharp burning pain in the
plus ; blood sugar, 0.095 ; blood urea-nitrogen,
10 mgm. ; blood Wassermann, negative.
Alcohol and pellagra. From the earliest days
alcohol has played a prominent part in study
of pellagra and pellagrous conditions. As far
back as the days of Zeist. the European litera-
ture abounds with case histories under the
name of pseudo-pellagra where no history of
maze consumption could be elicited. In those
cases chronic alcoholism was frequently found
to be a factor.
Olo’zag describes chichism in Colombia as
a disease clinically resembling pellagra, and by
Case No. 3
arms and noticed a few blisters, after which
the arms became dark-red.
Physical examination revealed an apa-
thetic, fairly nourished individual, with a
light brown pigmentation of face and neck,
but not more than would be expected of a
member of the Latin race. The tongue was
deep red, but no other abnormalities. The ex-
tensor surfaces of both hands, fore-arms and
arms to the upper third showed symmetric
pigmentation, with atrophic skin and fine
flaky scaling. Some of the areas showed
bright red lesions where the epidermis had
been denuded.
Laboratory findings: Urine, albumin 3
many authorities accepted as such, and caused
by abuse of a native alcoholic drink made
from maze and called chicha. Lie believes that
because of the increased use of chicha not
enough animal protein is consumed in the
diet, and we get pellagra-like symptoms. It is
interesting to note that with the decreased
use of chicha and corresponding increased in-
take of other foods there was a marked dis-
appearance of the disease in the city of
Medellin.
Y. C. Shattuck, reviewing 144 cases of pel-
lagra, reports 78% as abusing alcohol.
Joseph Goldberger considers alcohol to be
a chance coincidence in pellagra ; one acting
470
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
mainly by causing a chronic gastritis, inter-
fering with appetite and the proper food in-
take, and thus causing a decrease of protein
with an increase of salts absorption. With
these we must also consider the lowered body
resistance caused by alcoholism.
Light and pellagra. Goldberger quotes Fra-
pelli’s (177 1) first description of pellagra in
Italy and attributes the disease to the sun
rays. Gherardini (1877) held the same view
as to the sun being the causative agent. They
all succeeded in producing an erythema and
pigmentation of the back of hands in the pel-
lagrous by exposing them to the June sun for
a few days. These experiments certainly
were not well controlled, as lesions also occur
on nonexposed parts, while protection of
hands and fingers did not prevent appearance
of the eruption. Neusser (1887), examining
markedly pellagrous children in Roumania,
found the lesions confined to the hands and
feet while the rest of the body showed only
increased pigmentation. Goldberger and
Wheeler, in experimental production of pel-
lagrous lesions in human subjects, showed
cases where the first lesions were noted on the
genitalia ; not on exposed parts like the hands
and feet.
R. Crawston Low quotes Volpitio and Ron-
doni as causing hyper sensitiveness in pellagra
patients by injection of maze extract and ex-
posing them to the sun rays. Evidently some
toxins are produced in the circulation which
are activated on exposure to the sun.
Summary
During the hot summer months we meet
certain skin lesions which clinically cannot be
distinguished from those seen in cases of pel-
lagra. Without any exception all of our cases
were found in chronic alcoholics who exposed
themselves to the direct rays of the sun. It is
quite difficult to explain these skin lesions. It
is the accepted view, thanks mainly to the
works of Joseph Goldberger, Wheeler Svden-
stricker, and others, that pellagra is due to a
dietary deficiency in animal protein-amino-
acids, together with an inadequate mineral
salt supply, and that unknown quantity belong-
ing to the vitamin B complex. We can explain
the skin changes in alcoholic pseudo-pellagra as
due to a deficiency of the same elements in
the diet, but caused by the chronic alcoholism,
which acts as a food substitute, thus causing a
loss of appetite and diminshed protein intake.
Most of the patients are suffering with
chronic gastritis. Whatever food they do
manage to take is not properly digested and
we get a condition analagous to that found
in pellagra.
The direct sun rays act only as an exciting
cause on a tissue which has been lowered in
resistance by the dietary deficiency.
A GROUP OF ENDOCRINE CASES*
Frank J. T. Aitken, M.D.,
Bridgeton, N. J.
There are few syndromes in medicine so
interesting, curious and provoking as those
which are brought about by perverted func-
tioning of the glands of internal secretion. It
♦(Read before the Bridgeton Hospital Staff, Nov.
11, 1930.)
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
471
is regrettable that in the face of so many in-
teresting facts and cases of this sort that
there is so little teaching of this important
subject in the medical curricula. It is true
that the exaggerated claims of commercial
physicians and fanatics, who treat everything
with “glandulars”, have caused many of our
conservative practitioners to remain skeptical,
just as there are still many skeptics on the
subjects of heliotherapy and nonspecific protein
therapy. If common sense and sound judg-
ment, backed by the comprehensive knowledge
of endocrinology and metabolism, were applied
to the administration of “glandulars”, there
would be few disappointments in their use,
and many delights. It is indeed an easy mat-
ter to understand how many physicians bred
to therapeutic nihilism, in such schools as
Harvard and Yale, will become such ardent
believers in endocrine therapy that they could
be termed fanatics. All fanatics, however,
have the best of intentions.
It is the purpose of this paper to present
an unselected group of 9 cases, all of which
deal with a glandular dystrophy. For con-
venience in discussion, I will first mention the
gland involved and the name of the syndrome.
It will be necessary to be brief.
Case 1. Pituitary (diabetes insipidus). J.
M., a girl of 17, first seen on January 17,
1930, complaining of vomiting for 2 months.
No pain; no nausea; the vomitus was not
bilious, acid nor offensive ; occurred especially
on overloading stomach or under any excite-
ment. She admitted a voracious appetite, with
constipation, segmented stools, and a craving
for sweets and coffee. Her speech was hur-
ried and there was a marked tremor of the
hands.
Tentatively, I diagnosed a catarrhal gas-
troenteritis or possible chronic appendicitis
with a thyroid imbalance of girlhood. Her
diet was restricted on carbohydrates and cof-
fee, and she was placed on tincture of bella-
donna in 5 minim doses, and anesthesin and
menthol each gr. y2 t.i.d. On her return a
week later she was improved in all respects ;
no vomiting ; bowels regular ; tremor slight
and abdomen negative. For want of some-
thing better, I gave her Ignatia 6x, a remedy
of the homeopathic school of much value, in
hysteroid conditions.
Two weeks later she returned and with
triumph over modesty informed me of the
tremendous amounts of urine she passed. The
urine, on examination was normal, even as to
specific gravity. The blood sugar, urea and
Wassermann were negative. The male parent
submitted to the taking of a blood Wasser-
mann, which returned 3 plus. She was
placed on potassium iodide solution and mer-
cury by mouth. When seen on September 1,
8 months after the first visit, there were no
symptoms of disturbed function. She is now
taking Lugol’s solution 2 weeks on and 1
week off, and has not reported for observa-
tion.
Case 2. Pituitary (enuresis) . J. E., married
man, 22 years of age, first seen October 1929.
Father died of tuberculosis when patient was
8 years of age — implying a tuberculous in-
heritance. Family history negative otherwise.
Chief complaint : bed-wetting 2 or 3 times
every month. Personal history negative;
height, weight and nutrition ideal. No evi-
dence of focal infection. Urine repeatedly
negative. No history of excess in the good
things of life. Genito-urinary examination
negative ; no phimosis ; no prostatic enlarge-
ment.
Feeling there was little to lose in a trial of
pituitary extract, and all to gain in retaining
the cooperation of the patient, I placed him
on capsules of pituitary body posterior lobe
gr. 1 daily, with biweekly injections of 1 c.c.
of the extract, and after 2 months dismissed
him; requesting continuance of the gland by
mouth and to keep a record of his embarrass-
ing moments.
The patient returned in June of this year
as requested, and stated that for 3 months he
had been without enuresis. The dietetic bans
were withdrawn, as well as the medication,
and he has been instructed to report again this
month.
Case 3. Pituitary and thyroid ( Frohlich’s
syndrome) . M. L., American girl, 12 years of
age, first under observation June 1 this year.
Weight 160 ; pink, blooming and jolly. Her
complaints were fatigue on exertion or mod-
472
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
crate walking and abdominal cramps. She
started to gain weight at 10 years of age, as
had her mother and her brothers in their child-
hood. Has menstruated since 11 years of age
at irregular intervals averaging 3 weeks apart.
Has complained of fatigue since the onset of
her menses, which were painless and moderate
in amount, and has gained decidedly in the
few months before this history was taken, in
spite of a sensibly restricted diet.
Physical examination revealed marked in-
crease of fatty tissue, especially over the lower
abdomen, bips and breasts. Legs were slender.
Fingers long and tapering. Hands cold.
Widely separated upper incisors and abnormal
development of tbe lateral incisors. The heart
and lungs revealed no pathology. Pulse rate
90; greatly influenced by exercise. Tbe urine,
blood sugar, and Wassermann, the last of
which it is advisable to take in all cases of
obesity not influenced favorably by diet, were
all negative.
I placed her on a liberal diet and restricted
.■all exercise. By way of medication, anterior
pituitary 6 gr. ; thyroid gradually increased
■over 2 weeks to 10 gr. daily. In 2 weeks a
loss of 12 lb. was reported, and almost imme-
diate loss of abdominal pain, which I believe
was a cardialgia. The patient at this date, 4
months after her first examination, has lost
30 lb., menstruates regularly at 3 week in-
tervals, which to be generous I ascribe to the
medication, and she can enjoy longer walks
without fatigue. The thyroid has been de-
creased to 1/10 gr. 3 times daily and there are
no complaints.
Case 4. Thyroid (thyroid asthma). This
case I shall never forget because of the fear it
created and the respect for adrenalin. The pa-
tient was a girl of 14, 6 feet tall, precocious,
who for more than 3 months had been sub-
ject to almost continual paroxyms of dis-
tinctly asthmatic character. On her first visit
in March 1930 she stated she had been taking
injections of sterile water for the asthma, but
had never been treated for allergic manifesta-
tions as shown by skin tests. Closer examina-
tion objectively revealed widened palpebral
orifices with a staring expression character-
istic of exophthalmic goiter. Her mother had
a marked unilateral enlargement of the thy-
roid. An etiologic relationship of the hyper-
thyroidism to tbe asthma, naturally suggested
itself. Recalling the so-called Goetch test
(which is widely used in Great Britain in dif-
ferentiating toxic thyroid disease from simple
goiters, by a dermal reaction and also blood
pressure variations, from tbe injections of
adrenalin), I injected 2 minims into the girl’s
arm and in about 2 seconds she gave what
sounded like a death rattle and went cold and
flaccid. I reassured the mother and carried
her to the mechanical table, where treatment
was rendered. In a few minutes she regain-
ed consciousness, and at the same time had
the first complete freedom from paroxysms.
She was placed on belladonna and Lugol’s
solution. A week later she returned and said
she had only one spell of dyspnea which was
relieved by ys gr • of ephedrin. The next 2
weeks she had no attacks. She returned this
November, after a lapse of over 6 months
(although it was my desire to observe her at
closer intervals while on such potent medica-
tion), with a history of 3 days of paroxysmal
dyspnea. At this time her neck was quite
visibly enlarged and tense, and speech was
almost impossible. She had abandoned medi-
cation 3 months before this visit and had ap-
parently returned to a toxic state of thyroid
activity. Oral administration of antispas-
moclics and adrenalin was ineffectual and after
waiting 40 minutes, adrenalin 2 minims was
administered subcutaneously. There was a
marked reaction, approaching collapse and
followed by profuse vomiting. After the
vomiting the patient felt relieved and breathed
normally. She was again placed on bella-
donna and Lugol’s solution with admonition to
lie regular in office attendance, and to the
present date she has had no complaints.
Case 5. Pituitary (myxedema and neuro-
syphilis). This patient was referred to me on
September 18, 1930. Fifty-four years of age,
but presenile. Ocular examination revealed
changes in the discs and lenses similar to
those seen in arteriosclerosis, also a sagging
in both upper lids, and a granular conjunc-
tivitis. Complained of poor vision and diffi-
culty in raising the upper lids ; severe boring
pains deep in the eyes, and tugging on the
eyes, worse on the left. In other spheres her
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
473
chief complaints were shortness of breath,
failing memory, difficulty in locomotion, par-
ticularly in the dark, and disgust with every-
thing.
Physical examination revealed a myo-
carditis, subnormal blood pressure, moderate
anemia, facial tics about the mouth and eyes,
weakness of the grip in both hands, solid
edema of the wrists and below the clavicles,
sparsity of eyebrows, and a general yellow
tint to the skin. Diagnosis necessitated care-
ful consideration of the following conditions:
cerebro-spinal syphilis, Parkinson’s syndrome,
nephritis (Bright’s), pernicious anemia, and
advanced myxedema with arteriosclerosis and
myocarditis. I was inclined to favor the last
condition, in as much as the urine was nega-
tive, there was no history of progressive wast-
ing, and facies and gait were not sufficiently
characteristic for a Parkinson syndrome. The
Wassermann report had not yet been return-
ed. On the other hand, there were several
symptoms previously noted that are character-
istic of myxedema. History of influenza in
1920, from which it took the patient 6 months
to effect recovery, was judged to have a pos-
sible bearing on the present condition.
The Wassermann and Kahn returned posi-
tive. Treatment consisted of iodides and
mercury. There is little doubt, however, that
a pituitary dystrophy complicated this case.
Case 6. Thyroid (myxedema). S. L., a
single woman 44 years of age, was well until
1927, when she was operated upon for bleed-
ing hemorrhoids. A year ago last June she
had complained of progressive weakness,
dizzy spells and fainting, and increase in
weight. Her menses had ceased in 1928. On
her initial visit, June 1930, she stated that
she had been under the care of 13 physicians
since the onset of her symptoms. Physical
examination showed : Maximum systolic
pressure SO, diastolic 60 ; heart centrally
placed and of normal dimensions; pulse 130,
easily compressible, but regular in force and
interval ; cbest clear and resonant throughout ;
no edema nor ascites ; no abdominal masses ;
no splenic nor hepatic enlargement. Rectal
examination revealed an inflamed mass the
size of a large cherry with a tendency to pro-
lapse between the external sphincters. There
was no infiltration in the wall of the rectum,
but there were smaller hemorrhoids in the op-
posite longitudinal axis. Superficially, the pa-
tient was slightly yellow; skin was very dry ;
eyes muddy; face expressionless; hair brittle
and sparse ; hands pudgy, with thickened
joints; wrists enlarged with so-called solid
edema. A diagnosis of concealed hemorrhage
and myxedma was made.
At this time her hemoglobin was 25%. A
serious syncope attended the prick of a needle
and transfusion was adjudged dangerous.
Local measures were adopted for the rectal
pathology, and after 1 month of thyroid ex-
tract and iodide of arsenic her hemoglobin in-
creased to 45%, and I removed her hemor-
rhoids. A long and tedious recovery follow-
ed. Microscopic examination revealed charac-
teristic pathology.
Continuing the use of thyroid with strych-
nin and iron her hemoglobin in another month
had risen to 65%, and on November 10, less
than 6 months, became 80%. Along with
the increase in hemoglobin she has lost all
signs of myxedema, and is a very attractive
woman with a renewed interest in her music
and pastimes, a complete indifference to which
she had manifested for nearly 4 years. She is
the daughter of the patient with trophedema
whom I shall next describe. The maximum
dose of desiccated thyroid given to this patient
was 30 gr. a day. At present she takes a 5 gr.
thyroid tablet daily and no auxiliary treat-
ment.
Case 7. Thyroid (trophedema). Mrs. L.
M., mother of the previous patient. In this
case it is necessary to describe an unusual
condition.
Trophedema is a chronic neuropathic edema
occurring in segmentary distribution, associat-
ed with a hardening and pallor of the skin,
not due to cardiac or renal disease. Its diag-
nosis is made by exclusion of other diseases
which possibly could cause a similar condi-
tion of the limbs. Conditions which might
require differentiation are filariasis, cardiac
disease, nephritis, mechanical obstruction with-
in the pelvis which would disturb the local
venous lymphatic circulation to a marked de-
gree, and a bacterial form of elephantiasis
due to streptococcus. Lymphatic obstruction
474
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
in other cases is the result of severe or re-
current inflammation, as in erysipelas, milk-
leg, or other factors. Trophedema was first
described in 1898, but the pathologic basis has
never been clarified. It is evident that there
must be a disturbance of the trophic centers
within the spinal cord. In some cases neuro-
logic symptoms are present, such as hemi-
plegia and paraplegia, but this must be a
coincidence, for as a rule all other evidences
of organic diseases are absent. In r?ery iso-
lated cases it has been ascribed to traumatic
origin and interpreted as developing through
the mediation of an ascending neuritis which
climbs up and involves the spinal ganglion,
and from here to the constituents of the near-
by sympathetic ganglia. Some instances of
chronic trophedema have been observed in
which the swelling was associated with dis-
turbance of the ductless glands in the form
of more or less acromegaly or myxedema, and
that is the type of case into which my pa-
tient falls. The disease may be hereditary or
congenital, the infirmity being present at birth,
or it may be acquired, coming on at a variable
age, usually around puberty. In any event,
trophedema is to be interpreted as a familial
disease. It has been noted that in cases that
are hereditary, the disease is transmitted
through the maternal line, and that in a gen-
eral way men are not susceptible.
Mrs. M. is 65 years of age and appeared
older. Her features were acromegalic; stolid
expression ; a general yellowish tint. She gave
a history of having been treated for the past
year or more for variable conditions — -dia-
betes, myocarditis and chronic parenchyma-
tous nephritis ; the last mentioned had been
the favored diagnosis. She has been on a
high protein diet, and has been given urea in
doses of 30 grams daily without any reduction
in her edema. Has never had any ascites.
Unable to walk for over a year.
On my first visit I tentatively classified her
as a cardiorenal, having a great deal of re-
spect for the opinion and therapy of my
brother practitioners. However, at this time,
her heart and blood pressure seemed normal.
Both calves measured 20 inches in circum-
ference at the widest portion. I continued the
nephritin, also giving Niemeyer’s pills, and a
Carrel diet. Four days later, on my second
visit, aside from feeling stronger, she showed
no other changes and had. in spite of the limi-
tation of fluids, no increase in the amount of
urine passed. It was then that I decided her
condition might be trophedema, especially
since I had treated her daughter for myx-
edema.
On the third visit, October 14, there was
no change in measurements about the lower
limbs, the pulse rate had not changed, and
there was no noticeable difference in the gen-
eral condition except rest had been better.
Thyroid extract was the only medicine given
at this time and that in the equivalent of 15
gr. daily of the fresh substance. Urinalysis
on this occasion revealed a 2 -f- sugar which
patient stated has been the case for many
years. She has never had any diabetic symp-
toms, and the condition will be regarded as a
nondiabetic glycosuria, since these conditions
are present in myxedema. However, I omit-
ted sugar and limited carbohydrates, placing
her on a diet liberal in sea-food. On October
26, the measurement about the lower right
leg was 1 ?y% inches, a reduction of only %
in. She stated that generally she was feeling
much better. Thyroid continued 15 gr. a day.
Attempt at digitalization produced nausea on
lowering the pulse to 100. On November 4,
there were no complaints. Had attempted to
walk, but was unable to on account of pain.
Leg diameter 19 in., an increase rather than
a decrease. Medication : thyroid 10 gr. and
strychnin 1/50 gr. t.i.d. On November 11, the
leg diameter was 17 in. and considerable burn-
ing was present in the limbs, which I thought
was an encouraging sign ; a decrease of 3 in.
since the first visit. Continued medication. No-
vember 18 she complained of fatigue and re-
versed sleep rhythm. Thyroid was diminished
to 15 gr. daily. Leg diameter 17 in. Solid
wrist swelling entirely gone. November 26,
less fatigue. Leg diameter 16 in. Medication
continued.
It appears at this writing that the thyroid
substance is a specific, and I am almost opti-
mistic enough to predict that she will be able
to walk within a few months.
Case 8. Thyroid (myxedema). M. N., mar-
ried woman of 42, who is introduced because
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
475
of an indirect but interesting blood relation-
ship to the previous 2 patients, showing ma-
ternal transmission of myxedema. This pa-
tient’s grandmother, who had a goiter, was an
older sister to the trophedema patient. This
patient’s daughter has a hyperthyroidism, al-
though I have not yet had the pleasure of
studying this daughter.
Mrs. N. was first examined on No-
vember 10, 1930. She had complained for
the past 6 months of a sensation of a “fist
gripping her heart”, vertex headaches, dizzi-
ness on arising, extreme fatigue and mental
depression. She has gained in weight. Physical
examination revealed a distinct pallor, solid
edema of the wrists, absence of eyebrows,
deafness, and obesity. The only significant
clinical finding in a complete study was a
hemoglobin of 40%. Drawn to question her
relationship to our previous myxedema pa-
tient, I was delighted to find such existed.
She was placed on a liver diet, thyroid ex-
tract, and iron and strychnin intramuscularly,
and after 3 weeks of treatment presents no
symptoms of ill-being, and shows a hemo-
globin of 65%. The equivalent of 30 gr. of
fresh thyroid a day was given. She has lost
in that time 20 pounds.
In reviewing these and considering other
parallel cases the following thoughts pre-
sented themselves :
(1) In all so-called neurasthenic and hys-
teroid states it is highly advisable that func-
tional endocrine disturbances should be
sought. In obtaining history along the line
of endocrinology the family history should be
very carefully inquired into, even beyond liv-
ing generations, along the line of structural
abnormalities, asocial tendencies, or peculiar
diatheses. In dealing with children of any
age, it has always seemed to me that a pre-
scription given after interviewing the pa-
tient in the presence of the parents gives bet-
ter results than to prescribe for the child who
is unattended.
(2) In all chronic cases it should be as-
sumed that there is a complexity to their syn-
drome that has defied the routine forms of
treatment given by other physicians of equal
or greater intelligence (I believe all of us
have a certain routine which we try first, and
failing in that routine we really commence to
draw out our latent talents). Therefore, I be-
lieve we should at once, in these cases, elimi-
nate the possibility of deeply seated metabolic
disturbances of physiochemic nature.
(3) In all cases suggesting endocrine dys-
trophy the possibility of syphilis should be
eliminated.
SINUSITIS*
E. S. Hallinger, M.D., F.A.C.S.,
Camden, N. J.
When asked to present a paper on some
pertinent subject incidental to the season, it
followed that as the “common cold” is more
or less in the limelight of present day scientfic
investigation a complication of it would be a
fitting and appropriate subject to discuss. You
all know what sinusitis is, yet, like the old say-
ing that “familiarity breeds contempt”, this
very familiarity is often responsible for our
negligence to recognize self-evident facts, and
in the hope that some of you have acquired
this mental attitude I presume to present this
so common condition for your consideration:
Briefly, sinusitis is an inflammation, either
acute or chronic in type, affecting the acces-
sory nasal sinuses. These, as you know, oc-
cur in groups of 5, namely, the frontals, an-
terior ethmoids, posterior ethmoids, maxillary
antrums and the sphenoids. Each of these
sinuses has direct communication with the
nasal fossa by individual -ostei, and, anatomi-
cally, all are in direct relationship with each
other. Any or all of these cells may be in-
volved at the same time, either as a bilateral,
unilateral or unicellular infection, which
primarily may be induced by the following
causes, which for the sake of convenience may
be divided into 2 classes — local and general.
Under the first group we have the mechano-
physical conditions, e.g., nasal obstructions,
due to deflected or deviated septums, hyper-
trophied turbinates, spurs, polyps, new
*(Read at the Camden County Medical Society
meeting Dec. 2, 1930.)
4713
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
growths or abnormalities of the nasal walls
or bony structures ; while under the second
group we have the acute infections.
While it is true that an acute sinusitis may
occur without apparent, generalized, systemic
manifestations, it generally is the result di-
rectly or indirectly of an acute infective pro-
cess, or a complication of the same. Heading
this list is influenza, which produces about
75% of all the cases, depending upon viru-
lency of the epidemic. Next in order of fre-
quency come pneumonia, typhoid fever,
scarlet fever, measles, erysipelas, diphtheria
and cerebrospinal meningitis. Of the acute
infectious diseases scarlet fever takes the lead
and is usually more virulent in that the patho-
logic process is more destructive, even involv-
ing the bony walls of the sinus cavities, with
an ensuing involvement of adjacent parts.
Bacteriologically, practically every' case of
sinusitis is of the mixed type, although the in-
fluenza bacillus is frequently found alone. The
most common organisms, in addition to the
influenza bacilli are the pneumococci, meningo-
cocci, various varieties of staphylococci and
streptococci, and to a lesser extent the colon
bacillus and the diphtheria bacillus. Any or
all of these occur in single or multiple com-
binations, producing different types or degrees
of infection, the virulency of the latter vary-
ing with, the types of combinations.
It is not my desire to present sinusitis in
all of its many phases, as this would be a tre-
mendous undertaking, and an impossibility in
the time allotted, even if considered in but a
superficial manner, but rather to consider it
from a single standpoint, namely, that of the
“acute type”. This develops as the result of
an acute rhinitis or common head cold, or as
a part of the symptom complex of one of our
acute infections, the degree of involvement
depending upon: first, the nose affected; and,
second, the type of infection.
It is primarily essential that we have some
nasal pathology before we can have a sinus
infection, and upon this factor also depends
the degree or acuteness of the disease ; the
greater the obstruction, the greater the sus-
ceptibility of the patient to involvement. lake-
wise, the symptomatology varies with these
factors. The most pronounced symptom, ex-
cluding of course a generalized entity' such as
influenza, ty'phoid fever or pneumonia, is
headache. In fact, headache can he looked
upon as being the first symptom of sinus in-
volvement which follows a train of other pre-
liminary complaints, and it is of any type im-
aginable, both as to site and character ; it may
be spasmodic or constant ; neuralgic or hemi-
cranial, and violent to such a degree that the
patient is beside himself. It may begin first
as a dull ache which, however, gradually in-
creases in severity, and usually is present over
the site of the trouble — particularly if the
frontal sinuses are involved; in which case it
will be referred to the supra-orbital ridge or
to the nasal side of the orbit; or, if the pos-
terior group of cells is affected, we may
simply have a generalized type or the lower-
half headache, as described by Sluder, with or
without ocular manifestations, such as deep
orbital pain, photophobia and involvement of
the ocular muscles.
What are the mechanics of sinusitis? We
stated that the degree of involvement depend-
ed upon the ratio of nasal pathology rather
than upon the offending organism. One can
readily conceive that where the nasal fossa is
markedly narrowed or where the parts are in
close proximity to each other, as soon as the
mucous membrane of this fossa is congested
how quickly the resulting edema will produce
occlusion. It is but a step forward to imagine
what next occurs. As soon as engorgement
and edema have taken place there is an imme-
diate blocking of the nasal orifices of the
sinuses, particularly those of the frontals and
the ethmoids, with the result that ventilation
of these cavities is arrested. What happens?
There immediately ensues an absorption of
the residual air in these cells, and as the ab-
sorption continues a vacuum results ; the
greater this becomes the more pronounced
and severe will he the headache. In addition,
there is an increased flow of mucous secretion
which bathes the parts in excessive moisture,
heat is created and all air circulation is shut
off. What do we then have? — An ideal in-
cubating chamber.
It is not necessary to take up your time
with the mechanics of the ensuing pyogenic
process ; suffice it to say that this is the next
June. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
477
procedure, and, depending upon virulency of
the infection, may occur in a few hours or
within 2 or 3 days.
Then is the time when, in addition to gen-
eral symptomatology, the local evidence of
sinus involvement appears ; likewise varying
with the type of infection present, represent-
ing all degrees or phases of the pathologic
process from a simple benign condition, par-
ticularly when local nasal obstructions are in
the minimum, to the severest type met with,
and usually these are the cases that present
evidence of the greatest amount of mechanical
obstruction. Headache, of course, is present,
as previously mentioned, and at first is pro-
duced bv development of the vacuum and
later by the damming up of secretion and by
the establishment of contacts.
Local symptoms vary with the sinus in-
volved ; particularly true in cases of unicel-
lular sinusitis. For example, if the frontal is
the particular one, our local signs are directed
to it. These, in order of their occurrence, are
pain, tenderness, swelling and hyperemia. The
pain may be supra-orbital or may only be re-
ferred to the nasal side of the orbit, or may
include both areas at the same time. Pain
naturally increases in severity as the disease
progresses, while tenderness of the orbital
plate of the ethmoid may indicate an extension
of inflammation to the ethmoid cells. As
swelling develops, generalized pain and ten-
derness are found, particularly when hyper-
emia enters into the picture. This edema
usually affects the eyelid and the conjunctiva.
In addition to these evidences, we have at first
a fluent nasal discharge, which sooner or later
becomes purulent, the amount flowing being
dependent upon the drainage facilities and
upon the nasal obstructive pathology. Where
other than the frontal sinuses are diseased,
external evidences may be lacking. Diagnosis
then depends upon other signs. It is in this
acute stage, however, that immediate active
measures should be instituted; otherwise ser-
ious and even fatal complications are apt to
rapidly occur, with all of their concurrent
symptoms. These include, as the result of a
damming up of pus and increased intrasinus
pressure, empyemia and a generalized pan-
sinusitis, wfith an osteitis of the sinus walls,
which, ultimately eroding, permit rupture,
either into the orbit, with the formation of an
orbital abscess, or, the rupture may occur
through the cribriform plate via the olfactory
nerve openings, producing meningitis and
brain abscess. Optic neuritis and cavernous
sinus thrombosis are apt to be the particular
complications if the sphenoids are included in
the pathologic process; w'hile if the frontal
sinus is destroyed, in addition to rupture into
the orbit, we may have a progressive osteitis
of the inner wall of the sinus with a breaking
down of the same, development of a menin-
gitis and brain abscess ; or, instead of break-
ing directly through to the brain covering, a
suppurating, progressive osteitis may extend
through the entire cranium, creating multi-
ple pyogenic abscesses. This infection travels
through the diploic veins and may rupture
anywhere over the meninges, likewise result-
ing in multiple brain abscesses or a purulent
meningitis.
What are we going to do with these cases?
The first essential thing is, naturally, to create
ventilation, open up the nose and establish or
permit drainage. This holds good in any
phase of the disease and is particularly indi-
cated before sinusitis actually begins ; i . e . , in
the stage of congestion or hyperemia.
vHow can this be accomplished? By using a
shrinking agent that will deplete the engorged
or turgescent mucous membrane, and the best
agent in my experience is a 10%' solution of
cocain. Some prefer adrenalin or ephedrin,
alone or in combination ; be that as it may, the
essential thing to do is to shrink the mucous
membrane, and if this is done early, an attack
may be aborted. If seen later, it will occasion-
ally also be necessary to use suction, but this
must be done with care as we will accomplish
nothing if our vacuum is great enough to pull
out the mucous membrane of our sinus. Fol-
lowing the shrinking, use of a 10% solution
of argyrol on cotton tampons is indicated. To
be effectual these should be placed as high up
in the nasal fossa as is possible and allowed
to remain for at least a half an hour. It is
remarkable how quickly the flow’ of secretion
is started when these tampons are applied, and
more particularly upon their removal the
amount of relief obtained from their use.
478
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1031
Naturally, the amount of secretion removed
depends upon the degree of pathology present.
It is also permissible, following the use of
the argyrol tampons, to make light suction
followed by a soothing, oily spray. There are
some cases, however, which should be irri-
gated. This also depends upon the sinus in-
volved, and if the antrums are involved and
empyemic, they should be punctured and irri-
gated. Treatment will only be of use if our
patient has not an excessive degree of nasal
obstruction. If such exists it is frequently
necessary, and imperative, that these deformi-
ties and obstructions be removed before treat-
ment can be undertaken. Many times a radi-
cal operation upon your patient can be avoid-
ed by having taken care of the nasal path-
ology. However, in spite of what we do,
either conservatively or surgically, we reach
a point where every radical measure must be
used if we are going to save our patient, and
occasionally they die in spite of our efforts.
I have avoided going into a description of
the basic pathologic processes and likewise
have omitted reference to age limits ; but I
would like to say, in conclusion, that children
are more prone to sinus involvement than is
naturally suspected, and that all stubborn head
colds in children should be investigated. There
are many other factors to be considered, but
these will depend upon the type of condition
which was the underlying cause of the sinus
involvement and need no particular mention
here.
ONE YEAR OF NEUROLOGIC SERVICE
AT ST. PETER’S GENERAL HOSPI-
TAL IN NEW BRUNSWICK,
NEW JERSEY
Karl Rothschild, M.D.,
New Brunswick, N. J.
During the last 2 years of existence of the
old St. Peter’s Hospital, I had tried to in-
stal a neurologic consultation service and, in
the course of time, had found that this ser-
vice was not only a convenience but soon de-
veloped into a necessity, especially since, at
the same time, we had started a neuropsychia-
tric clinic, the attendance of which grew with
time.
When our new 200-bed hospital was finish-
ed a year ago, the staff found it proper to
create a full neuropsychiatric service which
takes care of 3 functions: (1) The neuro-
psychiatric ward service; (2) consultation
with other services; and (3) neuropsychiatric
clinic.
The 1 year of existence has proved so suc-
cessful that I feel it not out of place to record
what we have done, because it is my belief
that such a service could be easily arranged in
any community the size of New Bruns-
wick. I feel sure that some member of the
staff in every community hospital is especially
interested in neuropsychiatry and could take
charge of such a department. The nearness
of New Jersey to medical centers, besides, will
help to obtain consultation service whenever
necessary. It is a well known experience that
for no other kind of service does the public
run oftentimes to far-off places, as they do
with neurologic or psychiatric problems. This
fact is due to a certain indifference of the pro-
fession toward those problems which con-
sume a great amount of time and yet, in the
end, often turn out unsatisfactorily. Every
qualified hospital certainly should be able to
take care of the neurologic (with possible ex-
ception of the neurosurgic) and a large num-
ber of the milder psychiatric cases.
When looking over the records of the hos-
pital, we see that a great number of such cases
had always been admitted. Many neurologic
cases had been handled by the medical ser-
vice, without consultation. The surgeons
would frequently have liked to call in a neu-
rologist if only the expense had not been too
great. Many psychoneurotic patients had been
admitted and kept for a while, only to be
shipped away later to an insane asylum.
Let us consider the 3 types of service.
( 1 ) Ward service. The neuropsychiatric
service in our hospital has been established
within the group of medical services but as a
separate unit, just as the pediatric service.
That means that we have admitted to this
service all patients whose chief complaint was
on a neurologic basis, and we have made this
a matter of classification. Thus, a case of
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
479
tabes dorsalis is admitted to the neurologic
service. If during stay in hospital a medical
problem arises in this case, the medical ser-
vice is called into consultation. If, however, a
tabetic patient comes in complaining of trouble
pertaining to the medical field, he is admitted
to the medical service and the neurologist is
called into consultation. In this way, our ser-
vice has been very successful.
We have seen and treated a large number of
the milder neurologic and psychiatric prob-
lems but, on the other hand, we have also had
occasion to observe a great number of rare
cases, the diagnoses of which presented us
with great difficulties. Let us just mention
the following types : occlusion of a branch of a
vertebral artery ; traumatic pontine concus-
sion ; acute multiple sclerosis ; streptococcic
meningitis ; meningitis following a brain ab-
scess and caused by Bacillus mucosus capsu-
latus (Friedlander’s bacillus) ; Foville’s par-
alysis ; poliomyelitis anterior, superimposed on
syringomyelia; tumors of the cerebellum, 2
cases ; tumor of the thalamus ; pituitary
tumors, 2 cases ; general paresis with syphil-
itic disturbances of the circulatory system ;
and others.
Thus, it will seem that the diagnostic and
therapeutic possibilities of this service have
proved their value, even within 1 short year.
(2) Consultation service. Quite often has
this service been called in consultation by the
medical service in cases where neurologic or
psychiatric problems arose. I remember
specifically a case of indefinite pain in the pel-
vic region, which proved to be a pluriglandu-
lar disturbance and cleared up under proper
medication. We had a patient with chills,
resembling malaria, whose trouble afterward
turned out to be Korsakoff’s psychosis. We
had another case of Korsakoff’s psychosis,
which originally made us suspect sinus dis-
ease and which cleared up and the patient has
been healthy since. We have seen a great
many minor cases of hysteria, and especially
a large number of apoplexies where the medi-
cal aspect of the case was the prominent one,
and we were called in to determine the neuro-
logic status of the case.
We considered of special importance our
consultations with the surgical services. Here,
we had the opportunity to see a number of
brain injuries in which it was advisable to
make a definite, topical diagnosis as well as
a prognosis. Several times it was a matter of
differentiating between a central or peripheral
disturbance that caused the surgeon to call
our service in consultation. I remember one
of those rare cases — a brain injury causing a
flaccid paralysis, instead of the expected
spastic one — where the patient was worried
and our assurance that within a few weeks the
paralysis would become spastic was of great
mental and moral help to the sufferer. In an-
other case where there had been a head in-
jury, caused by an automobile accident, we
were called in for the reason that there was
flaccid paralysis of the arm with motor de-
ficiency, and which we could clear up by diag-
nosing a subcortical lesion ; and flaccid par-
alysis and apraxia will remain permanent
symptoms, accompanied by motor aphasia and
motor alexia, without disturbances of the sen-
sory functions. There were cases where a
neurologic status after peripheral lesions was
necessary, and here I remember a case where
an apparently harmless injury to the shoulder
had caused complete paralysis of the brachial
plexus. There were other cases in which a
concussion of the brain, without fracture of
the skull, was the sole injury, and where the
question of permanency of symptoms had to
be decided.
(3) N euro psychiatric clinic. In this clinic
we have seen many more neurologic cases
than straightforward mental ones, and a num-
ber of the cases referred to in this review
of the ward service were originally admitted
through the clinic. This 'fact may be due to
the presence of a State Psychiatric Clinic in
our city. We have felt that although this
state clinic was established we should not
abandon the psychiatric part of our clinic be-
cause: (1) We feel that handling of the aver-
age patient is not a matter for the state but
for the community or the hospitals ; the state
should confine itsdf to the treatment of defi-
nitely insane patients and not take up treat-
ment of psychoneuroses, and patients who do
not need hospitalization. (2) The state clinic
psychiatrist can see a patient only once a
month, and one does not need much imagina-
480
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
tion to figure out that this is not sufficiently
frequent for proper treatment. Our clinic is
held once a week, but it is possible to have
practically continuous service.
A number of school children with mental
defects have been referred to us. The New
Brunswick city school system employs a psy-
chologist who gives advice to the special
classes and classifies the children. It is a
common experience that the classification by
method of the Intelligence Quotient is very
unsatisfactory, and all the teachers of such
classes will agree with this statement. Besides,
many children with an I. Q. of 100, or even
higher, show defects in behavior and emo-
tions which can only be handled by a psychia-
trist. This is the reason why the number of
those children was so considerable. We have
diagnosed a number of them as glandular dis-
turbances and some experiences of ours with
thyroid deficiency cases have been extreme^
satisfactory. We have seen another series of
children who were suffering from infected
tonsils, obstruction of the nose, sinusitis, um-
bilical hernia, and other such “minor” troubles,
who were definitely benefited by removal of
these impediments. We have been frequently
in consultation with the pediatric and eye, ear,
nose and throat clinics. In the organic neuro-
logic class, we have seen cases of paralysis
agitans, paralysis following apoplexy, epi-
lepsy, postencephalitis, and tremors of various
origins. I especially remember a child of
about 14, with continuous shaking of her
limbs and body, certainly a case of posten-
cephalitis, who had gone to a number of agen-
cies. She improved greatly under administra-
tion of proper medication.
This clinic has also been an excellent means
tor the interns to see neurologic cases, as well
as for the nurses, who in a general hospital
usually have no opportunity to see patients of
this type.
It should also be mentioned that the writer
gave weekly lectures to the seniors of the
nursing school and that the nurses benefited
greatly by the possibility of actually seeing
cases of the various types, neurologic as well
as mental, during the lectures, and at any
time when such patients were admitted to the
service the nurses could he called together for
a “clinical conference”. It may also be men-
tioned that the superintendent of the nurses’
school asked the writer to give the probation-
ers a few introductory lectures on “every day
psychology, and the psychology of nursing
problems”.
The hospital authorities have been very co-
operative in helping us to establish and main-
tain this service. They have gladly admitted
milder mental patients who did not need special
supervision. They have provided us with the
necessary neurologic apparatus, but, above all,
they have shown acknowledgment of the value
of this service and done their good share in
improving it. especially by classifying the ser-
vice in its proper place and giving it a stand-
ing with the other services.
Looking hack over the first year of this
service, we have reason to be very well satis-
fied. This will not say, however, that satis-
faction means stagnation. There are many
problems to be solved. There are some of
the more complicated pieces of apparatus to
be installed. We are, at the present time,
without a high-type perimeter, and we have
not the possibility of using a permanent water
bath. Those things, I am sure, will come
within the near future.
Outside of these mechanical features, there
is one field in which, in my opinon, the ser-
vice is not yet called in frequently enough.
These are the cases of head injuries. We
feel it should be the rule that any head in-
jury admitted to the surgical service should
he seen by a neurologist if, as is the case in
our hospital, there is no special neurosurgic
service at hand. The greater number do not
present a serious surgical problem, most of
these cases being concussions accompanied by
scalp wounds. It is sad to say that most of
the severe injuries of the brain are beyond
medical help anyhow, hut in the remaining
class mentioned a neurologist ought to he con-
sulted, especially in order to determine the
amount of permanent injury before the pa-
tient leaves the hospital; this is especially im-
portant in compensation cases. We have
lately had 2 patients who had been properly
diagnosed as having concussion of the brain,
who had been discharged, but who had not
been able to work. Both were considered
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
481
hysterics who did not want to work. In both
cases, we found definite organic disturbances
due to multiple and diffuse hemorrhages in
different parts of the cerebrum.
This paper has been written with one idea
in mind : to demonstrate that a neuropsychia-
tric hospital service in a community like New
Brunswick is a possibility when the necessary
cooperation between members of the staff and
the hospital authorities is so well established
as at St. Peter's Hospital.
INDICATIONS FOR SURGERY IN DIS-
EASES OF THE THYROID*
William Barclay Parsons, M.D.,
Presbyterian Hospital Medical Center,
New York City
In treating diseases of the thyroid gland,
various methods are employed, from doing
nothing to the use of iodin, glandular ex-
tracts, radiotherapy, and operation. Surgery
probably has a wider application than any
other single form of treatment, being called
upon in the infections, tumors, and some of
the disturbances in physiologic function.
Infections. Acute infections of the thyroid
gland may appear with any of the acute in-
fectious diseases due to a streptococcus, but
usually they are associated with a generalized
pyogenic infection presenting abscess forma-
tion. Sometimes the infection will be localized,
appearing in a small abscess, but at times the
entire gland is replaced by a bag of pus. All
of these cases should be drained, but the more
fulminating type is associated with an ex-
tremely bad prognosis.
In the chronic infections, syphilis and
tuberculosis are occasionally encountered. The
former is, of course, nonoperative; the latter,
when discrete and localized, requires removal.
However, the diagnosis of tuberculosis of the
thyroid when it appears as a localized condi-
tion is almost never made. These cases are
frequently operated on for a suspected ade-
noma of the thyroid, with the true condition
*(Read at meeting of the Morris County Medical
Society, December 18, 1930.)
not being found until microscopic examination
of the specimen has been made.
The one chronic infection peculiar to the
thyroid is the iron-hard struma, first described
by Riedel in 1896. This condition is charac-
terized by a marked replacement of glandular
elements of the thyroid by an extremely hard,
dense connective tissue with a scattering of
lymphoid tissue throughout the tumor. Hashi-
moto, in 1912, described a condition in which
he noted a marked increase in the lymphoid
elements with production of huge germinal
centers and a decrease in the glandular ele-
ment. It is thought that the condition he de-
scribed represents the early stage, and that
described by Riedel the end stage of the same
process. The symptoms caused by the swell-
ing due to this marked increase in connective
tissue are mechanical in nature. Encroachment
upon the lumen of the trachea, and fixation of-
the latter, interfering with the rising of the
thyroid cartilage during swallowing, cause
dyspnea and dysphagia, which, with a visible
swelling, represent the main symptoms com-
plained of.
The main indication for surgery is relief
of tracheal obstruction. This may be obtained
by removal of merely the isthmus, but at times
a partial thyroidectomy is necessary to de-
compress the trachea. As little as possible
of the thyroid should be removed, because
there is a tendency for the condition to sub-
side, leaving the patient in a somewhat sub-
thyroid condition in most cases. This may re-
quire the use of thyroid extract for a period
of time, so that it is most desirable to leave
as much of the gland as is possible.
Neoplasms. Malignant -neoplasms of the
thyroid gland represent an incidence of about
2% in the surgically treated cases. Some
clinics report a considerably higher incidence,
and a correspondingly higher ratio of suc-
cessful operations. One suspects that many
of the virulent-appearing, so-called fetal
adenomas, which are absolutely benign
lesions, have been included, being mistaken
for carcinoma. The malignant neoplasms
seen are carcinoma, sarcoma, and malignant
thymoma. The latter 2 types are relatively
rare and are highly fatal. A fair percentage
of carcinomas are found while still within the
4S2
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
capsule of an adenoma, and 94% of cases
with carcinoma have a history of previously
enlarged thyroid. When this condition ob-
tains, partial thyroidectomy offers an excellent
-chance of cure. When the malignant change
is found diffused through the gland, even
though it may not be obvious beyond the
capsule, the prognosis, even with complete
thyroidectomy followed by radium or x-radi-
ation, is poor. To put it another way, if the
diagnosis of malignancy of the thyroid can be
made before operation, the prognosis is bad,
but if cancer is found on microscopic examin-
ation after an adequate operation for adenoma,
the prognosis is reasonably good. Fortunately a
fair percentage of cases with very hard, nodu-
lar glands that have caused pressure symptoms,
may have their hardness due to calcification,
so that a mistake in the good direction is
easily made in what appears to be carcinoma.
Sometimes this calcification is relatively
diffuse, and in such thin layers that a radio-
graph of the neck does not clearly indicate
the true nature of the condition.
Adenoma. One of the extremely interest-
ing conditions from both a theoretic and
practical standpoint is the group of cases
under the diagnosis of adenoma of the thy-
roid, whether with or without hyperthyroid-
ism. These are the nodular goiters, and there
has been considerable discussion as to their
etiology. Some believe that they arise from
cell rests present in the embryonic stage, the
so-called “cells of Wolfer”, cells similar in
all respects to the other embryonic thyroid
cells but not participating in the ordinary for-
mation of acini. This theory visualizes these
isolated groups of cells as living and growing
to produce, in one or more regions of the
thyroid, masses of tissue which in their ulti-
mate form may present a cellular arrangement
similar to that found in a normal thyroid
gland at any stage from the earliest embryonic
to a completely adult form, even to a degen-
erative form of the latter. One does find
adenomas in which the cellular arrangement
may be a solid grouping of thoroughly fetal
cells, an arrangement in cords, tubules, or
small acini, the presence of definite adult
acini, cyst formation, and lastly, calcification.
All of these are quite definitely changes
through which the thyroid cells pass from
their earliest form as they grow downward
from the tuberculum impar through the
muscles of the tongue to attain their eventual
site and adult arrangement in the lower part
of the neck.
The other theory as to their formation
takes into consideration the fact that the
thyroid gland increases its activity in re-
sponse to any energy demand, with a resolu-
tion to the resting stage after the energy
demand has been satisfied. In certain
individuals elasticity of the thermostat, as it
were, is deficient, with the result that in areas
groups of acini do not revert, but persist in
a hyperplastic state. For a period of time
this hyperplastic state is more morphologic
than physiologic, resulting in the persistence
of one or more areas of enlargement, which,
when it has occurred numerous times, pro-
duces a nodular goiter. Eventually, persist-
ence of physiologic over-activity appears, and
one then has a persistence of hyperthyroidism
which proceeds until the clinical picture of
the disease is in evidence. I find it hard to
believe that this latter theory covers all of
the miscroscopic findings, and feel that in all
probability both methods obtain. Certainly the
latter theory covers those cases in which de-
velopment of symptoms follows tonsillitis,
pregnancy, prolonged mental strain, psychic
trauma, and the various other occurrences
frequently associated with the onset of symp-
toms of hyperthyroidism. This will ascribe
an exciting rather than etiologic importance
to these various strains ; which is reasonable
in that all individuals are exposed to one or
more of these strains, and yet only a relatively
small percentage of individuals exhibit patho-
logic or physiologic thyroid changes.
The group of adenoma cases without
hyperthyroidism may require surgery. Cer-
tainly on the Atlantic seaboard the use of
iodin is unsatisfactory in individuals over 20
years of age. X-ray treatment has no effect
upon the size of these masses, so that if any-
thing at all is done it must be surgical. A
few years ago, several articles appeared upon
the danger of so-called iodin hyperthyroidism,
namely the development of hyperthyroidism
in an adenomatous gland consequent upon the
Jun?, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
483
use of iodin. In my opinion, such a circum-
stance is entirely coincidental. So many indi-
viduals have received iodin on the advice of
friends, druggists, advertising companies and
doctors, that it is not at all surprising to find
a fair number in whom symptoms have ap-
parently developed during the administration
of iodin. The earliest symptoms of hyper-
thyrodism in a patient with an enlarged thy-
roid of many years’ standing might easily
be worry over the goiter, and medical or other
advice would be sought. Iodin would be taken,
with control of the symptoms for a period of
time. Escape from control of the iodin would
then ensue, and there would be an apparent
development of symptoms consequent upon
the use of iodin. It also seems absurd that
the same substance would cause and help the
same group of symptoms. We do not use
iodin for the nontoxic nodular goiters, not for
fear of damage but because it would do no
good. There are 5 reasons for operation :
cosmetic, worry, the presence of tracheal ob-
struction, or even deviation, whether due to
enlargements above or below the level of the
clavicles, the likelihood of the development of
hyperthyroidism, and the likelihood of the de-
velopment of carcinoma. In young indi-
viduals with inconspicuous enlargements, I
believe it is safe and wise to do nothing. In
these cases the cosmetic effect, worry, and
pressure considerations do not appear, and the
likelihood of hyperthyroidism and carcinoma
can safely be considered as remote. Also,
following pregnancy or other energy demands,
there is apt to be an increase in size in the
small, impalpable masses which would be apt
to make their definite appearance following
operation ; and if operation is postponed at
least 1 operative procedure may be avoided.
In older individuals who have gone through
pregnancies and other tests, one can perhaps
consider that no further masses are liable to
appear, and that they are nearer the possible
development of hyperthyroidism of malig-
nancy.
The large, prominent nodules present no
need for delay. If the patient is worrying
over the goiter, operation is a small price to
pay for mental comfort, and the scar is always
less noticeable than the lump. Even moderate
tracheal deviation represents a certain hazard
with the development of upper respiratory
tract infections, and where there is definite
impairment of the airway, this hazard is a real
one, in addition to the considerable discom-
fort under which these patients labor.
It is hard to know what percentage of
simple enlargements will be later associated
with hyperthyroidism. In my own operative
experience, there have been 190 adenomas
without and 131 adenomas with hyperthy-
roidism, which represents, roughly, a ratio of
3 to 2 in the series. All one can say fronr
these figures is that there is a high incidence
of hyperthyroidism in nodular goiters. I have
already mentioned the 2% likelihood of malig-
nancy associated with this group of cases, so
that when one adds up the various points in
favor of operative therapy in this type of
case, it far outweighs the disadvantages of
surgery. The only deaths we have had in the
nontoxic group were due to pneumonia con-
sequent upon severe tracheal obstruction ne-
cessitating emergency procedures, and a pneu-
mococcus type III pneumonia in another pa-
tient who had auricular fibrillation and chronic
valvular cardiac disease.
The individuals with adenoma of the thy-
roid who have developed hyperthyroidism are
in general the older group of patients, and
represent a high incidence of cardiac impair-
ment. In an analysis of the results of partial
thyroidectomy in this group, 44% of the un-
successful cases presented persisting cardiac
symptoms. We feel that surgery is the
method of choice for this group, and employ
radiotherapy only for those patients in whom
the cardiac damage is so profound that oper-
ation would be almost certainly fatal. Even
in the presence of congestive heart failure of
considerable degree, prolonged rest will fre-
quently improve patients so much that with
an ordinary period of iodin preparation they
will stand surgery; and it must not be for-
gotten, as Lahey and others have frequently
emphasized, that these individuals have a
greater cardiac reserve than an ordinary
straightforward medical case of apparently
equivalent severity. However, it is of great
importance that operation be done before the
development of cardiac damage, not only from
484
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
the standpoint of diminished risk and short-
ening of the period of disability, but as shown
by the distinctly better results noted in the
follow-up clinic in the second group of cases.
A considerable degree of heart embarrassment,
as shown by heart-consciousness, dyspnea, and
even auricular fibrillation, may be consistent
with irritation rather than actual damage.
When this holds true, one would expect to
find little if any enlargement of the heart, as
shown by a teleroentgenogram, and but little
evidence of myocardial damage, as shown by
the electrocardiogram. A fair percentage of
cases will reestablish sinus rhythm early in
the postoperative course; in fact we have
noted it, in the electrocardiogram, on the
second morning after operation. If operation
is delayed until actual cardiac damage has oc-
curred, one can expect some improvement, to
be sure, but a certain amount of cardiac disa-
bility is certain to be present.
We do not differentiate from the standpoint
of treatment between the so-called adenoma
with hyperthyroidism and exophthalmic goi-
ter, considering that the hyperthyroidism is
qualitatively the same in the 2 types of cases,
and that the difference in clinical picture in
typical cases is due to difference in degree of
severity, and to difference in the ages of the
patients. The younger group, as a general
rule, presents a more fulminating hyperthy-
roidism ; the older individuals are apt to pre-
sent a higher incidence of cardiac involve-
ment. Both groups react to the use of iodin,
as evidenced by improvement in general con-
dition, pulse rate, gain in weight on a high
caloric diet, basal metabolic rate, and diminu-
tion of creatinurea when on a test diet lacking
in meat protein.
In the typical exophthalmic group we feel
that operation is ecpially the desired treatment,
with the following exceptions. In children and
at the age of puberty, mild hyperthyroidism
will frequently be controlled by life in the
country with forced feeding, rest, occasional
small doses of iodin and in some cases radio-
therapy. In patients around 20 years of age,
with mild symptoms and only a slight en-
largement of the thyroid, we frequently em-
ploy radiotherapy, and effect a satisfactory
percentage of cures. In the full-blown cases,
in individuals who have had one or more
bouts of hyperthyroidism in previous years,
and in the vast majority of patients over 25,
we feel that surgery is the method of choice.
This is based on risk and the follow-up re-
sults in relation to returned economic activitv
and to control of symptoms. In relation to
risk, it is worthy of note that the operative
risk is far less than the expected mortality in
the disease under medical supervision. Hyman
and Kessel, at the Mt. Sinai Hospital, several
years ago followed a group of 50 patients
who had refused surgery. These patients re-
ceived medical and psychiatric help, but in the
course of 5 years showed a mortality of 14%.
In all the clinics in the country where much
thyroid work is being done, the operative mor-
tality is in the neighborhood of 1%, which of
course compares very favorably with the mor-
tality just mentioned, and with other surgical
procedures of similar severity. In a recent study
of 18S cases, 90 % of patients had returned
to full economic activity by 12 months. From
the standpoint of symptom control, at 6
months, 74% were satisfactory in all particu-
lars; at 12 months 80% ; at 24 months 82%;
and at 36 months 89% were classed as satis-
factory. The percentage at 4 years was even
better, but the number of cases was too few
to warrant the drawing of any conclusions. At
these various periods of time, the unsatisfac-
tory cases presented, in the main, persisting
cardiac symptoms. Recurrences may be ex-
pected in perhaps 4%. The balance are
usually due to the persistence of one or more
of the nervous symptoms complained of prior
to operation.
The use of iodin in these cases is of ex-
treme importance • and unquestionably has
been the largest single factor contributing to
the lowering of operative mortality. It is
essential that if operation is considered iodin
should not lie used as a palliative measure ex-
cept in real emergencies. Individuals who have
received iodin for many weeks or months
usually are back at the point where they
started from, and one cannot hope for an-
other pharmacologic reaction. Striking im-
provement is noted in those patients who have
not received iodin previously, and they may
be operated on with every expectation of sue-
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
485
cess. The patients one fears now-a-days are
those who give a history of 15 or more years,
having received in that time all manner of
glandular extracts and iodin, and who present
a cardiovascular apparatus that has suffered
much wear and tear.
Another point not stressed sufficiently in
text-books and articles is the question of
marked exophthalmos. When the eyelids fail
to close at night, corneal ulceration in the sec-
tor below the iris may occur. If following
thyroidectomy there is not a prompt lessening
of the width of the palpebral fissure, a plastic
on the lid should be done to protect the eye
and to improve the appearance. Occasionally,
unilateral exophthalmos may be present, and
this has been helped by section of the cervical
sympathetic on that side, which results in the
production of ptosis on the operated side but
has no effect on the position of the eyeball.
Surgery, then, is indicated:
(1) To drain an abscess of the thyroid
gland.
(2) Remove localized tuberculosis.
(3) Relieve pressure from an adenoma or
Riedel’s struma.
(4) In carcinoma and other malignancies.
(5) For adenoma without hyperthyroid-
ism, to improve the appearance, to aid or pre-
vent pressure, and to avoid development of
hyperthyroidism and carcinoma.
(6) In cases with hyperthyroidism, as a
method with a high percentage of cure and a
low element of risk, particularly as a safe-
guard before cardiac damage has occurred ; or,
in the presence of cardiac damage to effect
improvement in symptoms and interrupt the
vicious cycle.
OBSERVATIONS IN THE VIENNA EYE
CLINICS*
A. Russell Sherman, M.D.,
Newark, N. J.
In speaking this evening about the Vien-
nese eye clinics, I should like first to describe,
for those who have not visited Vienna, the
general plan of instruction and the oppor-
*(Read before the Eye, Ear, Nose and Throat
Section of the Academy of Medicine of Northern
New Jersey, Newark, Feb. 9, 1931.)
tunities for attending clinics there; and,
secondly, to mention some of their present day
ideas and practices, particularly those that
differ from our own.
The teaching, as a whole, is excellent. One
may at times object to the subject matter as
being too elementary or too advanced, too
practical or too theoretic, but it is usually diffi-
cult to find fault with the manner in which it
is presented. The chief reason for this high
quality teaching is perhaps a financial one.
With the exception of those holding the rank
of “professor”, the average of Viennese prac-
titioners connected with large hospitals has no
private work worth mentioning. The relation
between his hospital hours and office hours
is approximately reversed, as compared with
ours, which means that he spends 8-10 hours
daily in the hospital. Of this time, some is
devoted to the handling of patients and a
small amount may be taken up by under-
graduate medical students. For this work he
receives, I believe, somewhat under $1000 a
year and must, of course, pick up something
additional. Therefore, he offers post-grad-
uate instruction and, as a result of the man-
ner in which such courses are conducted, the
best teacher is most in demand and makes the
most money. A popular instructor may be
teaching 5, 6 or more hours daily, and by
constant repetition, commencing another
course as soon as he finishes an old one, he
naturally becomes very proficient.
There are a great many courses given in
English, and all of them, according to an
agreement wTith the University of Vienna, are
under the auspices of the American Medical
Association of Vienna; an organization of
English speaking medical men from various
parts of the world who are in Vienna for
post-graduate work. Any one, therefore, who
wishes to take any of the English courses,
joins the Viennese A. M. A., which occupies
rooms in a building across the street from the
Vienna General Hospital. There, he finds
posted on bulletin boards lists of all the avail-
able English courses. These courses ordinarily
cover 1 hr. of instruction daily for 6 to 25
days, and classes may be limited to a few
men, or may be unlimited. They begin some-
times on a definite date, sometimes as soon
486
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
as the quota is filled. The charge of $5 or
$6 an hour is divided among the members of
the class.
There are 2 or 3 disadvantages connected
with these courses, namely, delay while waiting
for a course to begin, occasional conflict when
one finds 2 courses that he wants scheduled
at the same hour, and the very elementary
character of much of the work.
Besides receiving formal instruction in this
way, one may also become a “hospitant”. This
means only that he pays a monthly fee of
$10 which entitles him to spend- as much time
as he chooses in the clinic, the ward, and the
operating room, examining patients and ob-
serving treatments. For any one who already
has an elementary knowledge of a chosen
specialty this is probably the best way to pro-
ceed, for at the same time he will probably
have an opportunity to take a few courses
that seem particularly desirable.
Most “eye men” going to Vienna for the
first time probably expect to find the patho-
logic work very good, but many no doubt
wonder if the Viennese may not perhaps prove
to be a little backward in other respects. With
2 exceptions, nothing could be farther from
the truth. The average American will be
shocked at their ideas concerning muscles ;
which include postponement of squint oper-
ations until the age of puberty, and entire
disregard of the existence of a fusion faculty;
also at their use of proprietary drugs without
knowing or apparently caring what is in them.
In general, however, they are quite up-to-date
in their ideas, adopting anything new which
seems desirable, whether it be American,
European or Asiatic, and developing usually
their own modifications and improvements.
The clinic equipment is also extremely
modern and complete. One wonders how, in
a country as poor as Austria, so many ex-
pensive instruments can be had for his-
pital use, while many institutions in this
country have poorer equipment than a prac-
titioner requires for his office work. For ex-
ample, the 2 eye clinics at the general hos-
pital have, besides a good supply of the or-
dinary eye instruments for clinic work and
teaching, 2 Gullstrand ophthalmoscopes, 3 or
4 slit-lamps, a machine which projects ordi-
nary lantern slides, microscopic sections, and
opaque objects such as drawings and charts ;
and a surgeon works in the operating room
with the aid of 3 Zeiss hammer lamps cluster-
ed above him and has at hand a fourth which
may be held by a nurse or assistant.
The teaching in ophthalmology, having been
under the control of the elder Fuchs for so
many years, is probably on a higher plane
than that in some of the other specialties. An-
other good feature is that it is carried on al-
most entirely in the General Hospital, so
that one is npt compelled to take 15 or 20
minute trolley rides from one hospital to an-
other. The eye work in the General Hospital
is taken care of by 2 clinics, the first or Meller
clinic and the second or Lindner clinic, each
having its own examining, treatment and lec-
ture rooms, its own wards and operating room,
and also its own ideas about diagnosis and
treatment, so that for all practical purposes
they could be separated by a few hundred
miles instead of the few hundred feet they
are. Apparently, the one thing that in a way
connects them is the Fuchs tradition, for al-
most all the men studied under him, Meller
having been first assistant in his clinic for 17
years.
In accordance with the teaching of the elder
Fuchs they emphasize the clinical rather than
the laboratory side of ophthalmology, and
their approach to a case is based always on
anatomy and pathology. This tendency to get
at and keep in mind the fundamental changes
producing any particular clinical condition is,
unfortunately, in striking contrast to our own
often very superficial manner of considering
our cases and is, I believe, the one feature of
their work that is distinctly outstanding.
Guesses are not made about the pathologic
changes in eye disease. If microscopic sec-
tions of the condition have been studied, they
are described; if not, one is simply told that
no cases with a pathologic examination are
known. One would imagine that under such
conditions, considerable lack of knowledge is
expressed concerning cases seen in the clinics,
but this is not so. There is a very complete
cross index and follow-up system in the
clinics, so that a patient with an interesting
eye condition can be followed for years and
June, 11)31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
487
if, as often occurs, he comes to the hospital to
die, or his body is brought into the morgue,
the eye will in all probability be examined
under the microscope in comparatively short
order. Only under such circumstances could
anyone write the book which one of the mem-
bers of the Lindner clinic is now preparing
on fundus diseases, and which is to contain
a history of each case, a drawing or photo-
graph of the fundus, and one or more photo-
graphs of microscopic sections of the enu-
cleated eye.
It is by means of this record system, too,
that some remarkable fundus cases can be
collected for the classes in ophthalmoscopy.
A man who is giving a course in fundus dis-
ease often has postcards sent to patients he
wants to exhibit and is able to show on one
day optic atrophy, the next day optic neuritis,
the next chorioretinitis, detached retina, con-
genital anomalies, or practically anything de-
scribed in the average fundus atlas. Some of
these patients receive their car-fare and an
Austrian shilling for coming to the clinic;
others nothing ; and practically all of them
sit patiently in the dark room for an hour
while they are examined and reexamined by
10 to 15 persons.
The lectures will, in general, prove disap-
pointing to the eye man of average experience
who hopes to discover some miraculously new
methods of diagnosis and treatment. They
often contain very little of practical value,
except to the beginner, but do touch on many
subjects which can make the practice of oph-
thalmology more complete and interesting —
such as : Why does a patient with macular dis-
ease see comparatively better at night than in
the daytime? Why is a Morax-Axenfeld con-
junctivitis in the angles of the conjunctiva?
Why are catarrhal ulcers found in their
characteristic location? Why is an iris blue,
or green, or brown?
It is possible, and highly desirable, for one
who is going to Vienna to study ophthal-
mology, to avoid some of the inconveniences
of the short courses by taking the so-called
Fuchs’ course. This is a rather concentrated
series of lectures, practical clinical hours and
laboratory periods which has been given dur-
ing 8 to 10 weeks in the Fall for the past 7
years. It is intended for men who have had
previous experience, such as an eye internship
or other elementary training, and is under the
direction of the younger Fuchs who makes a
sincere and rather successful effort to have
each subject taught by the best teachers avail-
able.
I want now to mention more specifically,
though I am afraid it will be rather discon-
nectedly, some of the ideas and methods in
vogue at present in the large Vienna clinics
and in the clinic of Elschnig, at Prague, who
is, by many competent observers, considered
the outstanding man on the continent.
There is nearly always considerable differ-
ence of opinion anywhere concerning opera-
tive methods, and it is especially significant to
find certain procedures followed routinely in
3 independent clinics, as they are in regard to
cataract extraction. In each of these clinics
the cataract operation is performed with
round pupil, with a fixation suture in the
superior rectus tendon, and with akinesis of
the lids by novocain injection. In regard to
other features of the operation there is less
uniformity. Both Elschnig and Lindner do
the intracapsular operation routinely, dilating
the pupil before operation, suturing a rather
large conjunctival flap, and instilling eserin
after the operation. Lindner excises a small
piece of iris peripherally after extraction of
the lens, and Elschnig simply makes a small
peripheral iridotomy with a sharp-pointed de-
Wecker scissors immediately after the in-
cision, without removing any iris or touching
it with forceps.
In the Meller clinic the capsulotomy opera-
tion, with peripheral iridectomy and small
conjunctival flap without sutures, is routine,
the intracapsular operation being reserved for
immature and hypermature cataracts. Meller
lays stress on the importance of opening the
lens capsule with capsule forceps rather than
with the cystotome, in order to remove as
much of the anterior capsule as possible, thus
preventing, partly, the inclusion of cortical
matter between the 2 layers of capsule and the
formation of a secondary cataract. He also
calls attention to the delayed healing which
follows inclusion of a small tag of lens cap-
sule, often invisible in the wound, and feels
488
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
that preservation of the round pupil tends to
prevent this complication. It is interesting,
however, that after discussing this and other
advantages of the round pupil, he concludes
by saying that in very old people and in one-
eyed patients a complete iridectomy should be
done. Preliminary iridectomy is done only
in those cases where a swollen, cataractous
lens is producing some secondary glaucoma;
never preparatory to extraction of an uncom-
plicated cataract.
In the operative treatment of glaucoma it
is the general practice to perform an iridec-
tomy in acute cases. In chronic cases Meller
uses the trephine, Lindner the iridencleisis,
and Elschnig the cyclodialysis. Meller states
that cyclodialysis is the best operation for
glaucoma in the aphakic eye. In the Vienna
clinics, attention is called to the frequency of
late infection, i.e., 1 year or more after op-
eration, in eyes which have had an Elliot
trephining; Meller stating that in his cases it
has been 7%. In the Lindner clinic late in-
fections occurred in 16 cases out of a series
of 342.
A bacteriologic examination of the con-
junctival sac before operation is not done in
the clinics of the Vienna General Hospital.
Lindner gives 2 reasons why they have stop-
ped this procedure ; that there are always bac-
teria in the conjunctival sac, and that simple
examination of a smear from the conjunctiva
is insufficient for certainly detecting organ-
isms there. His investigations have convinced
him that most bacteria in the conjunctiva en-
ter into the cells and are, as he says, “epi-
thelial parasites”. He believes very strongly
in the efficacy of 1% silver nitrate, according
to the method of Bell, of New York, which,
he says, brings about coagulation of the super-
ficial conjunctival cells. These cells, contain-
ing most of the bacteria present in the con-
junctiva, are then washed out by the routine
irrigation upon the table at the time of op-
eration.
Considerable work is being done with the
Gonin cautery operation for retinal detach-
ment. This has been developed intensively in
the Lindner clinic, where a rather elaborate
method of finding and localizing the retinal
tear is in use. The patient sits with his eye
in the center of a large, heavy brass ring,
graduated in degrees, to which is attached a
semicircular arc with its convex side toward
the observer. This arc rotates about the vis-
ual axis of the patient’s eye, and carries an
electric ophthalmoscope of die tubular sort.
By rotating the arc, and sliding the ophthal-
moscope along it, the observer examines sys-
tematically the entire fundus, and indicates on
a chart the position of any holes or tears
found. The horizontal meridian of the eye
is then marked by 2 dots of india ink, placed
nasally and temporally, just outside the lim-
bus. At the time of operation, a metal indi-
cator, consisting of a ring concentric with the
limbus, is sutured in place over the cornea.
This ring carries one or more limbs which ex-
tend out radially, following the curve of the
sclera backward, and previous to operation
they are adjusted and trimmed off so that the
tip of each lies over a retinal tear. These posi-
tions are then marked by touching the sclera
with the cautery tip, the indicator is removed,
and the operation performed. By this
method, Guist, in the Lindner clinic, has
found retinal tears in 95% of the cases ex-
amined, and of those in which a tear is pres-
ent, has found 2 or more tears in 90%.
Very recently, because of the diffuse de-
struction of chorioidal and retinal tissues by
the thermocautery, they have substituted cau-
terization of the chorioid by fused potassium
hydroxide, after exposing the area by a scleral
trephine.
Nonsurgical treatment of eye conditions in
the Vienna clinics is very much the same as
here.
In regard to diagnosis, their ideas are some-
what different from ours, and their methods
of examination occasionally better because
they are more thorough and exact. Keratitis,
iritis, chorioiditis, etc., that we frequently
consider the result of some hidden focus of
infection, are called tuberculous, and although
the existence of such a thing as focal infec-
tion is admitted, its importance is not con-
sidered very great.
At this point, it might be well to mention
the views of Prof. Hirsch, the rhinologist,
concerning the relation of sinus disease to
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
489
optic neuritis. He states that only 8 to 10%
of cases of retrobular neuritis arise from sinus
infection, and calls attention to the fact that
a suppurative inflammation is not essential to
optic nerve involvement; a catarrhal inflam-
mation with the resulting osteoporosis being
quite sufficient.
In ophthalmoscopy, red- free light is fre-
quently used for studying cases of retinitis
and neuritis. The younger Fuchs says that in
his practice, ophthalmoscopy with red-free
light is almost of as much importance as ex-
amination with the slit-lamp.
Patients refracted under a cycloplegic are
examined by the method of cylinder skiascopy
elaborated by Prof. Lindner. This is an ex-
tremely accurate objective method which de-
pends essentially on the fact that when 2
cylinders are crossed at an oblique axis there
is formed a sphero-cylinder combination with
its axis lying somewhere between the axes of
the crossed cylinders. It will be seen that if
the astigmatic eye is considered a cylindric
lens which we are attempting to neutralize by
another cylinder of opposite sign placed in
the same axis, some rather odd retinoscopic
shadow will be observed when the neutraliz-
ing cylinder is placed4 before the examined
eye at an incorrect axis. Lindner has sys-
tematized these skiascopic pictures and has
put forth some practical working rules, so
that this method is now used routinely both
in his own and in the Meller clinic.
LEUKORRHEA, ITS SIGNIFICANCE
AND TREATMENT
P. Brooke Bland, M.D.,
Philadelphia, Pa.
In considering the symptomatology of mor-
bid conditions of the reproductive organs of
women, I have always found it a convenience,
as well as a special advantage, to divide the
subject into: (1) symptoms arising in the
body at large, or what one might denominate
systemic or general symptoms; and (2) those
having their source in the genital organs them-
selves, which I customarily refer to as pelvic
or local symptoms. While the first group
must be looked upon as of very definite clini-
cal importance, the latter are infinitely more
significant, not only from the standpoint of
diagnosis but more especially from the as-
pect of etiology.
I have always felt that the association of
numbers aided the student in not only grasp-
ing but retaining certain fundamentals of the
subject, and I have pointed out that numeri-
cally in the second group, there are 5 out-
standing symptomatic expressions of both
physiologic and pathologic processes. One or
all five symptoms may be present. In the
order of frequency they may comprehensively
be enumerated as: (1) Leukorrhea; (2) al-
tered menstruation; (3) bleeding; (4) pel-
vic discomfort, at times expressing itself in
actual pain; (5) and finally, irritability or
dysfunction of the adjacent organs, namely,
the bladder and bowel.
In order of frequency, leukorrhea occupies
the foremost place. It is present in all patho-
logic conditions involving the genital organs.
It is not only the most frequent, but the most
significant local symptom as well. Generally
speaking, it is the first symptom to appear and
the last to cease. Before discussing, how-
ever, this clinical manifestation of pelvic dis-
ease in detail, it seems incumbent that some
utterance should be made with reference to
the so-called natural secretions. I am led to
adopt this plan because, first, there seems to
be some misunderstanding regarding this fea-
ture of genital physiology and, secondly, be-
cause without an intelligent conception of the
normal secretions it is obviously impossible
for one properly to comprehend and interpret
the abnormal.
The vaginal secretion. Since there are no
glands in the vaginal mucous membrane, the
small quantity of fluid present must be gen-
erated partially by the squamous epithelial
cells lining the canal and partially by osmotic
processes. Physically, the vaginal secretion is
bluish white and resembles both in color and
consistence ordinary skimmed milk. Generally,
on separating the labia, it is found only in
small quantities. Usually there are observed
only a few droplets escaping from the vag-
inal orifice.
Chemically, the material is highly acid in re-
f
490
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
action. This has long been ascribed to the
presence of the vaginal bacillus of Doderlein,
but, since the acidity pursues a more or less
cyclical course, it has been suggested that the
reaction may in some way be governed by en-
docrine activity. At any rate it is assumed,
and quite properly too, that the special chemi-
cal character of the secretion is an exceed-
ingly important factor in nature’s defensive
mechanism.
The cervical secretion. The secretion elab-
orated by the cervical mucous membrane is
frequently compared to the white of an egg.
This is entirely erroneous, because it is
wholely devoid of color. Strictly speaking,
it is as colorless as the purest crystal and only
assumes a whitish hue when coming in con-
tact with the acid secretion of the vagina.
In pregnancy, as a result of this chemical
combination, a thick, white, tenacious mucoid
plug, the operculum, forms in the cervix,
blocking the external os and forming, there-
by, another factor of noteworthy importance
in the barrier of defense. It is the operculum
— stippled or stained with blood — discharged
with the onset of uterine contractions that
constitutes the show, the first positive sign
heralding the advent of labor.
The uterine secretion. The secretion elab-
orated by the endometrium is of small im-
portance clinically, nor is it of special moment
diagnostically. It is physically somewhat like
water in color and consistence, and chemi-
cally it is alkaline in reaction. It becomes of
some importance when excessive, as for ex-
ample, in that rather curious condition known
as hydrorrhea gravidarum.
With this rather sketchy introduction, I
shall now try to answer a question that I am
quite confident occupies the minds of the ma-
jority of the members of this assembly, namely,
my object for selecting a topic for discussion
so elementary as leukorrhea. There are sev-
eral reasons why I elected to discuss the sub-
ject.
(1) I believe that one should always en-
deavor to consider a theme of practical value.
(2) I am quite convinced the best inter-
ests of all are served not by presenting a
topic of ultrascientific proportions, but one
commonly met with in every day clinical
work. I have found that most of our scien-
tific meetings are attended largely by inen in
general practice and it is to these, provided
one has a message, that the message should be
conveyed.
(3) I was persuaded to speak of leukor-
rhea because one must recollect that it is fund-
amentally a symptom ; not a disease, but an
expression of disease. It, hence, becomes ob-
vious that the cause of the symptom, rather
than the symptom itself, must be determined
and treated.
(4) It is prudent to recall that leukor-
rhea may have a simple etiology and respond
to a simple therapeutic plan. On the other
hand, its cause may be more or less obscure,
not susceptible to recognition by ordinary
means of examination, but only after pains-
taking microscopic scrutiny.
(5) It is important at this time to em-
phasize that one of the most frequent causes
of leukorrhea has heretofore only occasionally
been recognized.
(6) I further elected to consider the topic
because the condition is treated, as a rule, in
a most unscientific and perfunctory manner.
(7) It is now quite generally conceded
that many cases have been treated hitherto on
the assumption that they had their source in
gonorrheal infection. Patients of all ages,
from infancy to senility, may be found in this
category.
(8) Because of the prevailing, if not per-
nicious, habit of regarding most cases of en-
docervical origin, and treating them as such.
(9) Because a most frequent form, if not
the most frequent form of all, though first
described 95 years ago, has been until quite
recently grossly overlooked. In our Antenatal
Clinic we find this type of disease more fre-
quent than venereal infection.
(10) Finally, because to the cervix, in
many cases, destructive cauterization has per-
niciously been performed, with the infection
resident in the vagina and not in the structure
cauterized.
It might be of interest at this time to say
that historically one finds reference to leukor-
rhea in the oldest medical literature extant ;
recently I had occasion to peruse abstracts
from Eber’s Papyrus, written some 1500
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
491
years before Christ, and, parenthetically, you
may be stirred to learn that at last this most
celebrated record has been translated into
English. Reference, moreover, to the symp-
tom is found in the earliest biblical literature,
literature which antedates the Egyptian docu-
ment by some 35 centuries.
I have already directed attention to the fact
that there is scarcely a single disorder arising
in the generative organs of women without
leukorrhea as a conspicuous accompaniment.
Considering the symptom from its purely
pathologic aspect, one finds that its clinical
character may be almost as variable as its
causation. For example, in simple vaginitis
the discharge is usually of a thin, watery,
catarrhal or suppurative type. In venereal in-
fection it is found as a thick, irritating, sticky,
pyogenic discharge. In malignancy, involving
either the vagina or the cervix, it appears as
a serosanguineous, malodorous, burned-beef-
juice material.
In a form now recognized as exceedingly
common, it manifests itself as a free, copious,
thick, yellowish, offensive, irritating, bubbly
or foamy discharge, and it is this variety that
I have chosen to talk about tonight. It was
first described by Donne, in 1836. The symp-
tom may be experienced in individuals of all
ages and it has been transmitted from woman
to man. This type of leukorrhea is associated
with lesions more or less typical, involving the
vaginal mucous membrane, especially the
membrane of the fornices and the surface of
the vaginal portion of the cervix. These are
found as small, punctate, hyperemic or granu-
lar areas in the anatomic situations named.
Bleeding is readily excited by any form of
manipulation.
It has been observed that the endocervix is
singularly free from morbid alteration in this
form of infection and it is almost, if not al-
together, safe to say that the cervical mucous
membrane is rarely, if ever, affected. This
is a noteworthy feature of the trouble, so
much so that one may be axiomatic and affirm
that, with a discharge of the nature I have
described and the cervix relatively normal,
trichomoniasis may be looked upon with a
fair degree of certainty as basically the pro-
voking factor. In other words, with the dis-
charge presenting the typical features enumer-
ated and with the cervix visually free from
trouble, one is justified in making a diagnosis,
provisionally at least, of trichomonas disease.
Confirmation as to the cause of the symptom
is readily determined on microscopic study,
by finding the field, literally, flooded with
parasites of unmistakable identity, namely, the
T richomonas vaginalis.
Treatment. With regard to the therapy of
leukorrhea, it is apparent that no form of
medication ever should be instituted without
first determining its cause. Since in many in-
stances infection of the endocervical mucosa
is the source of the trouble, therapy directed
to this region, especially in the form of cau-
terization, is almost invariably followed by
amelioration. In this connection, however, I
cannot too strongly emphasize the absolute
futility of therapeutics of this type in Tri-
chomonas vaginitis. I have already referred
to the fact that the endocervix seems curiously
immune to the ingress of the parasites. We,
as well as many other workers, have never
found the organism within the cervical canal.
It can readily be perceived, therefore, that it
would be wholely illogical to expect a favor-
able response to medication directed to this
structure.
Here may I reiterate that no case of leukor-
rhea should ever be treated without its ex-
citing cause first being determined. Any other
course in the long run will prove unsatisfac-
tory and may even court embarrassment. In
this respect, may I crave your indulgence
while I recite the clinical record of a patient
who recently came under my care. She is
34 years of age and the daughter of an em-
inent physician. At the age of 2 years, she
developed what was regarded as a gonorrheal
infection of the vagina. Since that time, or
for a period of 32 years, this young woman
has been treated with more or less constancy,
without permanent release from her most dis-
tressing symptom. Since cervical cauteriza-
tion has gained a wide popularity as the ac-
cepted mode of treating leukorrhea, the patient
had this type of therapy applied on 18 dif-
ferent occasions. During the past 2 years, 2
cauterizations were performed under anes-
thesia. At the present time, there is no ves-
492
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
tige of a cervix. It has been totally destroy-
ed. The external os, or rather the mouth of
what remains of the cervical canal, is on a
level with or, rather, continuous with the
vaginal mucous membrane.
Three months ago, she came under our ob-
servation with the clinical record cited. A
local examination disclosed the typical thick,
yellow, rather offensive irritating, bubbly dis-
charge, with the typical lesions, consisting of
turgescence of the labia, engorgement and
hyperemia of the lower section of the vaginal
mucous membrane, punctate areas of hyper-
emia and granulation in the upper part of the
vaginal canal, especially in the fornices and
surface of the cervix. A tentative diagnosis
of the cause of her annoyance was made im-
mediately and confirmation was found on mi-
croscopic examination, with literally hordes
of trichomonads obscuring the microscopic
field. Under treatment the patient, now for
the first time in years, is not only free from
the parasitic infection, but the annoying
leukorrhea and the lesions have entirely dis-
appeared.
With reference to the type of therapy in-
stituted in cases of vaginal trichomoniasis, one
may say at the outset that there is no specific
recourse. It is important, however, to men-
tion that early cases are usually responsive,
while old or long standing ones prove fre-
quently most obdurate.
USEFUL IRRIGATING FLUID FOR
SEPTIC WOUNDS*
H. H. Goldstein, M.D.
Elizabeth. N. J.
For the past 3 or 4 years, in cases with
septic wounds, we have been using an irri-
gating fluid which has been a source of great
satisfaction to us in so far as clearing up the
infection was concerned, and having been
(juestioned frequently as to the method of pre-
paring the solution, it appeared that a note
on the subject would not be amiss. We have
*(Read before the clinical society of the
Alexian Brother’s Hospital, Elizabeth, N. J., Dec.
9, 1930.)
reference not to superficial wounds, but to
those deep-seated affairs which have a habit of
draining foul pus for an extremely long time.
It does not matter whether the sinus leads into
the peritoneal cavity or whether it is extra-
peritoneal. It has been used with gratifying
success in ruptured appendices, tuboovarian
abscesses, perinephric abscesses, and a host
of other deep-seated septic conditions. The
solution is never used until a definite sinus is
formed. Usually, the surgeon will allow suffi-
cient time for a sinus to form before the
drains are removed. If, after the drains are
removed, a sinus persists in discharging pus,
then the irrigating fluid is indicated. The
greatest benefits are derived in cases infected
with pyogenic organisms ; our experience with
the Koch bacillus has not been happy.
The irrigating fluid is prepared by adding
to warm saturated boric acid solution a suffi-
cient quantity of ordinary U. S. P. tincture
of iodin to give the whole an amber color. The
solution must always be made up freshly, and
strength of the solution will depend on the
severity of the infection and location of the
sinus. If the sinus reaches into a walled-off
area in the peritoneal cavity, the solution
should be made weak ; while in a foul peri-
nephric abscess a fairly strong solution may
be used. One never adds so much iodin that
a burn may result.
The best results are obtained by using a
catheter for the irrigation. An ordinary two-
holed, soft rubber catheter is inserted to the
bottom of the sinus, and with a large 5 oz.
asepto-syringe the solution is gently injected
and allowed to run out along the catheter. Suc-
tion will remove whatever small quantity of
solution does not run out of its own accord.
The irrigation may be repeated every 2-3 hours
for the first 3-4 days, and then once a day
until the infection has been cleared up. The
irrigating fluid serves a double purpose. It
mechanically washes away the pus and debris,
at the same time acting as a bacteriocidal and
bacteriostatic agent. These latter properties
are still further enhanced by the evolution of
nascent iodin from the warm solution (iodin
being volatilized at room temperature) and
from the splitting of the hydriotic acid which
is formed in the boric acid solution.
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
493
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J.
Entered at the post office at Orange, N. J., as second-class matter
PUBLICATION COMMITTEE
HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J.
EDITOR:
HENRY O. REIK, M.D., P.A.C.S., Vermont Apartments, Atlantic City, N. J.
Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to
receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fact.
NOTE. — The transaction of business will be expedited, and prompt attention secured if:
All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to
The Editor, Dr. Henry O. Reik, Vermont Apartments, Atlantic City, N. J.
All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements,
or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication
Committee, (address above), Newark, N. J.
INTERESTING INFORMATION CON-
CERNING “OLD GOLDS”
In February we directed attention to the
character of advertising matter used by the
makers of Lucky Strike cigarettes. In April
it was the “health crusade” to benefit the
manufacturer of non-spit-tipped cigars, that
concerned us. Now, you may be interested to
learn something about the methods used —
again reflecting upon the medical profession — -
to force the sale of Old Gold cigarettes.
You probably saw in your favorite news-
paper a quarter or half page advertisement
of “Old Golds”, consisting largely of a pic-
ture allegedly portraying a group of physi-
cians and nurses in a hospital operating room,
capped and gowned as for a surgical pro-
cedure but suspending the professional rou-
tine while the surgeons tested the relative
merits of certain brands of cigarettes. The
surgeons were said to be throat specialists,
who found Old Golds as kind to your throat
as luckies ; in point of fact, kinder. The ad
also bore the imprint of Ripley, of “Believe it
or not” fame.
We wrote to Mr. Ripley that we did not ,
and asked for proof that any throat specialist
had participated in such a test and authorized
such use of his professional character. No re-
sponse has come from Mr. Ripley, but the
newspaper from which our clipping was taken
passed the inquiry on to the agency that had
arranged for publication of that advertise-
ment, and ultimately we were invited to in-
spect the records.
Accepting that invitation, we visited the
agency’s office in New York and had a very
satisfactory conference that resulted in ex-
posing the fraudulent character of the Old
Gold statement. We discovered, in the first
place, that the picture was “faked” ; i.e., it
was not taken in any hospital, but was staged
in a studio. Next, we were shown the list of
physicians’ names-— alleged throat specialists — -
appended to the advertising contract. From
the list of 7 names of “throat specialists”, we
selected 3 (chosen because they happened to
be the most legible, for investigation. One of
those 3 names has not been found in any di-
rectory; one is the name of a physician who
is not a throat specialist, and not a member
of his county or state society; the third is a
member of his county society and, of course,
of the American Medical Association, but is
not recognised as a throat specialist. We re-
gret now that we did not copy the entire list
of 7 names, but the relative results would
probably not have been different.
So, as stated before, the advertisement
seems to have been fraudulent ; the picture
was faked and the posing physicians were not
throat specialists. We are concerned about
such advertising not only because it is so
flagrantly dishonest, but because we object to
such exploitation of the medical profession,
and we think the time has come to expose all
such schemes. If American “big business” is
based upon such rotten practices, it is no won-
der that it is now tottering.
494
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
Medical Ethics
UPHOLD HONOR OF THE
PROFESSION
John Hammond Bradshaw, M.D., F.A.C.S.,
Orange, N. J.
The obligation assumed on entering the pro-
fession requires the physician to comport him-
self as a gentleman and demands that he use
every honorable means to uphold the dignity
and honor of his vocation, to exalt its stand-
ards and to extend its sphere of usefulness.
A physician should not base his practice on an
exclusive dogma or sectarian system, for “sects
are implacable despots ; to accept their thral-
dom is to take away all liberty from one’s ac-
tion and thought”. (Art. I, Sec. 1, Principles
of Medical Ethics, A.M.A.)
There are many excellent physicians living
not far from this vicinity who still think that
a written code of ethics is altogether unnec-
essary for our profession. Strict in their own
personal relations to ethics, they cannot un-
derstand why all doctors should not be gen-
tlemen. But in the writer’s very limited ex-
perience he has met with several physicians
who were not gentlemen and, if they observed
any golden rule, it was the rule to acquire as
much gold as they could without too much
nicety of observation of ethics. It is possible
that readers of this article can think of in-
stances when they themselves had like ex-
periences. Others cannot be perfect (?) like
ourselves! We have often heard speakers ex-
claim that if other men felt and acted as they
did about the liquor question, there would be
no need of a Prohibition Amendment. Per-
haps they are right. Nevertheless, the writer
firmly believes in a written code of ethics, and
the more he scans the little booklet called
“Principles of Medical Ethics”, given to any-
one upon request by the American Medical
Association, the more he appreciates the wis-
dom of its authors and the actual need of its
study and its general adoption.
We sometimes roll under (and over) our
tongue a morsel of professional scandal.
Should we not rather know that when doing
this we are fouling our own nest? In other
words, by avoiding doing this, we are up-
holding the honor and dignity of our voca-
tion.
We sometimes would like to tell our friends
and patients that our regard for old Dr. Bluff
is so small that we ourselves “would not call
him in to attend a sick cat” (but just why a
sick feline should be singled out for this pub-
licity, the writer actually never found out).
The writer is proud to tell that he once knew
William Osier and can affirm (with all Dr.
Osier’s friends) that this great physician al-
ways had some good thing to say about oth-
ers, even about his enemy (if he ever had one,
which is sincerely doubted).
It seems so silly to stir up strife when by
taking the opposite course one can keep all
one’s friends, be healthier, wealthier, more
contented, and even keep one’s blood pres-
sure down around normal.
Esthetics
MAKE YOUR OWN MURALS
(An article by W. R. Storey, reproduced from the
New York Times Magazine, Sunday, Jan. 18, 1931.)
A new form of wall ornamentation, the
“photo-mural”, has recently been developed.
Through photography, a drawing, a printed
picture or a small photograph may be enlarged
to the size of a wall panel or even extended to
cover the four sides of a room. Already these
photo-murals have been applied to interiors of
homes, cafes, clubs and offices with marked
success. Professional interior decorators
have achieved some of these results, but any
one using the method may ornament his walls
with pictures of his favorite sports, historic
scenes or landscapes.
Although more expensive than most wall
papers, the photographic murals are less costly
than a similar decoration done by hand. They
vary from about $1 to $2.50 a square foot,
depending on the amount of detail involved,
and can be hung by any paperhanger.
The individuality that may be achieved by
this new form of wall decoration is shown in
a dining room in the New York home of
Owen Winston. Jones & Erwin, pioneers in
the new murals, covered the walls with photo-
graphic panels by reproducing old prints of
special significance to the owner. A scene
picturing the New York postoffice about a
hundred years ago serves as an overmantel
decoration, while the old Grade mansion and
the original Astor residence form subjects for
panels. The early-American atmosphere of
the room is carried out by a fine Colonial din-
ing table and chairs.
Following the eighteenth-century vogue of
painting walls in imitation of fabrics, a dress-
ing room in the Winston home has its walls
covered with a photographic representation of
drapery whose vertical folds are formally
regular and decoratively flat. Two vases on
pedestals — important details of a Directoire
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
495
room — have been cleverly photographed and
made part of the wall covering.
More picturesque is the wall treatment of a
Chicago home, in which the giant sequoia for-
ests of California furnish the motifs. The
vertical lines of the huge trees, running from
floor to ceiling in soft-toned enlargements
along the whole wall, impart to the room a
sense of dignity, quiet and spaciousness that
only a forest can convey. Tables and chairs,
constructed from the same redwood in rough
woodman’s style, stand on the Indian rugs
covering the floor.
Man’s conquest of the air is depicted in
full-length, black and white photo-murals in
a private dining room of the Cloud Club, high
in the Chrysler tower. From the first balloon
ascension in Paris a century and a half ago
to the latest giant plane hovering over the
skyscrapers of New York, the history of
aeronautics emerges graphically on the walls.
The romance of oil, with views of picturesque
oil fields with derricks and storage tanks, is
portrayed in similar fashion in a second din-
ing room of the club, while the making of
steel, with furnaces, forges, and skyscraoer
■construction, forms the subject in a third.
Restaurants also use the photo-mural effec-
tively. Thus, the college inn room of the
Hotel Sherman, Chicago, utilizes an original
sketch by the Negro artist, Aaron Douglas.
Although the sketch itself, which depicted the
origin of jazz music and the modern dance,
was only 12x20 in., the flat masses of the
artist’s design enlarged so effectively that the
murals for an entire room were obtained.
Several business offices have adopted this
■original mode of ornamentation. A banking
firm has covered 2 sides of a room with a
large-scale map of the world ; a concern
manufacturing electric motors has ornamented
its showroom with heroic-size pictures of its
product, hand-colored in the actual hues ; a
business man who is also a huntsman has
decorated the walls of his office with a pano-
ramic picture of a hunt of the Genesee Val-
iev Hunt Club.
Other uses for photo-murals include the
decoration of screens. Old prints of famous
landscapes or park scenes — an old Saratoga
print, for example — are appropriately em-
ployed for this purpose. An amusing design
was developed by enlarging an old-fashioned
Spencerian pen sketch. Even personal exper-
iences may be immortalized by the photo-
mural process. A picture of an African big
game hunt has been enlarged to adorn a screen
in the office of George Eastman at Rochester.
A photo-mural may be of almost any size.
While the special paper employed is generally
only 40 in. wide, sections of the picture may
be printed on separate pieces and the com-
position joined together when the strips are
hung on the wall. If, during the enlargement,
the image is projected through the coarse
meshes of bolting cloth, a soft fabric texture
will result.
Quiet color effects are obtained by the use
of gray or sepia paper, although other hues
may be put on by hand. Color should be ap-
plied clecoratively rather than realistically.
Oils, pastels and water-colors have been found
successful, but almost any painting medium
workable with paper can be used for coloring
the enlargement. The finished paper is some-
times coated with varnish to protect it and
provide a soft, antique effect; some loss of
brightness and color, however, must be al-
lowed for when this is done.
Although sepia and black-and-white paper
produce interesting and dignified results, more
definite and livelier colors may be given to
these wall decorations. A transparent tint
composed of photo-oil color combined with
turpentine may be rubbed over the enlarge-
ments after they are hung. Some satisfactory
hues are burnt sienna, lemon chrome yellow,
deep chrome yellow, ultramarine blue, mad-
der lake, tolicline red and Milori blue.
In Lighter Vein
For Sobriety, Try a Monocle
She was only the optician’s daughter — two
glasses and she made a spectacle of herself. — Pitt
Panther.
Tip for Travelers
For a cure for seasickness
A reader appeals.
A plan he might try is
To bolt down his meals.
- — Boston Transcript.
Dolled Up for Sun Bathing
“Clothes do not make the man.”
Observe the dandy’s—
If further proof’s required
Just gaze at Gandhi’s.
— Boston Transcript.
Sometimes we dally with the vagrant thought
that birth control would have more to recommend
it if it could be made retroactive. — Weston (Ore.)
Leader.
Archeologists have found a skeleton with the
knees crossed behind the head; so the art of
dressing in an upper be’"*'h probably isn’t new. —
Toronto Star.
If the wife laughs at your jokes, you can be sure
that either you know some good ones or you have
a good wife. — Los Angeles Times.
496
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
Annual Report of the Treasurer
193 1
PERMANENT FUND
DR.
June 1, 1930 —
2 M 1st Liberty Loan 3 V2 % bonds .. $2000.00
4 M 4th Liberty Loan 4 14 % bonds . . 4000.00
Mortgage Certificates, Investors’ Title
& Mortgage Guarantee Company. 2700.00
June 14 — -
Cash from Reserve 3000.00
$11,700.00
CR.
May 31, 1931 —
2 M 1st Liberty Loan 3V2% bonds. $2000.00
4 M 4th Liberty Loan 4%% bonds. 4000.00
Mortgage Certificates, Investors’ Title
& Mortgage Guarantee Company. . 2700.00
Mortgage Certificates, Trenton Mort-
gage & Title Guarantee Company.. 3000.00
$11,700.00
GENERAL ACCOUNT
Receipts
Payments
Balance, June 1, 1930
Assessment s —
Atlantic $ 1815
Bergen 2880
Burlington 765
Camden 2040
Cape May 375
Cumberland 750
Essex 11995
Gloucester 480
Hudson 6570
Hunterdon 390
Mercer 2205
Middlesex 1785
Monmouth 1330
Morris 1245
Ocean 225
Passaic 3360
Salem 225
Somerset 660
Sussex 315
Union 3640
Warren 375
Interest
Publication
Health charts sold
$17,947.52
43,425.00
914.57
8,850.46
5.20
For Publication Committee $14,748.30
“ Publication Special clerical 100.00
“ Welfare Committee 672.38
“ Credentials Committee 394.02
“ Executive Department:
Salaries .... $14,000.00
Travel 2,645.82
Office 3,641.49
20,287.31
“ Treasurer’s Office 65.00
“ Secretary’s Office:
Salary $ 1500.00
Expenses 2196.91
3696.91
“ Delegates to A. M. A., R. R. fares.. 187.28
“ Printing and Stationery 1884.81
“ Legal Services 988.47
“ Tristate Conference 126.62
“ County Secretaries’ Conference .... 150.90
“ Expenses of Guests, 1.930 Meeting . . 249.62
“ Flowers, Dr. Dickinson’s Funeral . 25.00
“ Subscription, N. J. Legislative News 25.00
“ Refund to Dr. Hillegas 20.00
Reserve 3000.00
Balance, May 31, 1931 24,521.13
$71,142.75
$71,142.75
RECONCILIATION
Expected Income
Actual Income
Appropriations
Expenditures
Operating Net Balance
WITH BUDGET
$48,450.00
53,195.23
48,450.00
46,621.62
5,573.61
Respectfully submitted,
E. J. Marsh,
Treasurer
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
497
Lighthouse Observations
MANAGEMENT OF ANGINA PECTORIS
A very practical discourse on this topic was
presented by A. E. Vipond, of Montreal (Amer.
Med., 36:789, December 1930), from which we ab-
stract the following- :
“This name does not convey to one’s mind the
agonizing pain, the mental anguish, and the tragic
death. How many of our personal friends and re-
lations have suffered from this, hopeless form of
heart disease?
This heart trouble may develop slowly and a
patient might live for many years, an attack tak-
ing place when he oversteps his limit or capacity;
as long as he can keep within his capacity, both
mentally and physically, he may do very well. He
soon learns what he can do and how far he can
walk before his heart muscle finds it difficult to
contract.
The filling up of the lumen of the coronary ves-
sels may take years to accomplish, or again, spasm
or a thrombus may occlude the lumen of the ves-
sel and sudden death may take place at an early
stage of the disease.
It is a disease which is no respecter of persons.
It is most frequently found among the great men-
tal workers, and also among men and women who
live a quiet life and who have no severe mental
worry or strain. It is also found among housewives,
clerks, policemen; people who cannot be accused
of great intellectual weariness.
There comes a time with most of these patients
when the slightest exertion will produce the pain.
As a rule, it is a progressive disease; all depending
upon the amount of occlusion of the coronary
vessels.
The majority of patients who suffer from angina
pectoris have not had syphilis. During the past
2 years I have treated 6 patients with this dis-
ease and not one of them had syphilis. In this noil-
luetic type of angina pectoris we do not find an
inflammatory change in the coronary vessel wall,
but a degenerative process; an atheromatous con-
dition; while in the syphilitic type we have an in-
flammatory change in the vessel wall — a mesaor-
titis; while the same changes take place in the
coronary vessels.
In the majority of my cases no change in the
heart condition was to be detected; as a rule the
sounds were not quite so loud as in normal sub-
ject: and if an organic valve condition were present
it was caused by a previous rheumatic infection.
Angina pectoris is a very common cause of death
among physicians, and many eminent men in our
profession have succumbed to this disease. John
Hunter suffered from angina pectoris for 20 years,
and after his death his coronary vessels were found
to be calcified. Sir James MacKenzie, Charcot,
Nothnagel and William Pepper all died from this
disease.
Granted that the cause of angina pectoris is
disease of the coronary vessel walls, what pro-
duces the pain and sudden death? To me, it does
not appear to be a difficult problem to solve. If
the lumen of the coronary artery is lessened by
disease of its coats, part of the circulation to the
myocardium is cut off ; the result is that when
the patient is sitting, he, as a rule, feels no diffi-
culty, but as soon as an extra strain is placed upon
the muscle (which is already suffering from a
diminished blood supply), the left ventricle dilates
suddenly and the patient suffers from this severe
pain in the chest, and down one or both arms, as
well as from great mental distress. A keen ob-
server can pick out these anginal patients as they
walk along the streets. They stop suddenly and
stare into a shop window and then continue their
walk as soon as the agonizing pain is over.
Frederick Price states that the hypotheses which
have been advanced in explanation of the attack
are numerous and include the following 2 which
are important: (1) That angina pectoris consists
in the distention of an enfeebled ventricle. (2)
That it consists in a myocardial ischemia generally
due to an affection of the coronary arteries
(atheroma, functional contraction, thrombosis,
etc.) ; this ischemia being the direct cause of the
pain.
I pin my faith to 2 drugs, viz., potassium iodide
and to belladonna. The potassium iodide must be
pushed; we must get the momentum of the drug.
I give 30 gr. in a cup of water to be sipped during
the daytime. I mean by this, sip a little every
half hour; it can be taken in a bottle in the pocket
and sipped while at work. My patients; also get
8-10 minims of tincture of belladonna. The potas-
sium acts as an alterative, and the belladonna
dilates the coronary arteries and their branches. I
give 60 gr. of potassium iodide with 10 minims of
tincture of belladonna to my chronic cases, and
this foi'm of treatment is kept up for weeks and
months with no remissions.
Amyl nitrite is not required. The patient can-
work if it is of a quiet character, such as office
work. Avoid excitement and getting into a tem-
per; exercise according to his capacity- — he will
soon find out what his capacity is.
With this form of treatment I can get results
that are lasting. None of these patients have de-
veloped iodism.
Amyl nitrite is not required when this form of
treatment is administered.
Current Events
TRISTATE MEDICAL CONFERENCE
The seventeenth session of the Tristate Medi-
cal Conference was held on Saturday, February
28, 1931, at the Pennsylvania Hotel, New York
City, at 10 a. m., Dr. Joseph S. Lawrence, of Al-
bany, presiding in the absence of Dr. William H.
Ross, President of the New York State Medical
Society, who arrived later. Those in attendance
were :
New York: Drs. William H. Ross, Brentwood,
Long Island; Frank Overton,, New York City; and
Joseph S. Lawrence, Albany.
Pennsylvania: Drs. Ross V. Patterson, Phila-
delphia; Walter F. Donaldson, Pittsburgh; Frank
C. Hammond, Philadelphia; and Harry W. Albert-
son, Scranton.
New Jersey: Drs. George N. J. Sommer, Tren-
ton: John F. Hagerty, J. B. Morrison, Newark;
Spencer T. Snedecor, Hackensack; and Henry O.
Reik, Atlantic City.
Dr. Reik: As Secretary, I have nothing special
to report but I would like to call your attention
to the absence of one of our Pennsylvania repre-
sentatives who has been most faithful in attending
these conferences ever since he was chosen as
President-Elect of the Pennsylvania State Medical
Society. Dr. Morgan is absent because of the
recent death of his wife, a death which recalls
the subject of our last meeting when we discussed
automobile accidents. Mrs. Morgan suffered a
498
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
fractured skull from an automobile accident which
occurred, I believe, last summer. I would like to
put in the minutes an expression of regret at Dr.
Morgan’s absence, and an expression of sympathy-
in his recent bereavement.
This was unanimously approved.
Dr. Lawrence asked if there was any business
to be brought up before beginning the regular
program.
Dr. Donaldson said that he was authorized by
Dr. Mayer, the President-Elect, to extend a hearty
invitation to the conference to hold the next meet-
ing in Pennsylvania, and in Pittsburgh, if it met
with general approval.
Dr. Reik : Remembering the last time we were
in Pittsburgh, I am sure we should be very glad
to go back there. I move that we accept Pennsyl-
vania’s invitation to hold our next conference in
that state, and leave it to the President and Secre-
tary of the Pennsylvania Society to decide the
time, place and program.
This was unanimously approved.
Regular Program
What Are State Departments of Labor Doing to
Advance Industrial Surgery?
Dr. Lawrence: I have in mind to conduct this
part of the program as a round table discussion.
I have no set paper. I am going to introduce sub-
jects and give my point of view, and would like to
get yours in return. As an introduction, I shall
tell you something about the organization of a
Department of Labor in New York State. I pre-
sume you probably have similar organizations in
your states. I know that there are some differ-
ences but whether they are material or not we can
develop. Our department is headed by a Com-
missioner, a lady who has among her qualifica-
tions for this particular job the experience derived
from chairmanship of a legislative committee that
was appointed years ago to make a study of the
sweat shops in New York City. Her committee,
I think, started really as a local voluntary organ-
ization and after securing state authority extended
beyond New York City to other large cities in the
state. It is said that without question she prob-
ably knows more about factory work in this state
than any other single individual because of her
various personal inspections and years of exper-
ience. She is assisted by an Industrial Board of
5 members appointed by the Governor. They pre-
sent no qualifications aside from the fact that they
are familiar with industry and problems that the
Department of Labor might take up. Of course,
as a State Department of Labor she has the assist-
ance of the Attorney General’s Department when
she needs it. She hfis also an Advisory Committee
composed of 10 members, 5 of whom represent in-
dustry and 5 represent federated labor, but this
group has no mandatorial powers; she need only
consult them at her will and may take their advice
or not as she chooses. From experience, however,
I think that she relies upon them to a great ex-
tent and finds their advice very valuable. I have
sat in several times at conferences, that she has
called, where they considered not only subjects
which you would expect them to be very familiar
with, that is subjects relating directly to industry
or labor, but medical problems as well. These 10
men were her advisers on matters that affected
administration of the Workman’s Compensation
Act. Then she has several volunteer committees,
on codes and rules, that she consults also at her
pleasure.
There is a Deputy Commissioner in each of
various other cities, like Rochester, Buffalo, and
Syracuse, in addition to the officers in New Y’ork
City. And then, she is directly head of the State
Insurance Fund; and the latter is growing to be,
if it is not already, the most extensive carrier of
insurance in the state. As a matter of fact, I
believe it was said not long ago that it carries an
amount almost equal to that of all the other car-
riers, and there is a bill in the legislature now
that would make it incumbent upon communities
and municipalities that carry insurance to take
such insurance from the State Insurance Fund
instead of from private carriers. That, if made
law, would leave the private carriers only such in-
dustries as would want to go to them. This bill
also pi'ovides that the State Fund may carry pri-
vate insurance if requested. So, it may be only a
few years until the insurance work in New lrork
State will be carried by the state and the self-
insurers. Labor is back of this movement; medi-
cal men are not. In New York City the State
Fund operates very satisfactorily but up-state
physicians tell us that they have more difficulty
in getting settlements from the State Fund than
from any other carrier.
Of course, the Commissioner of Labor controls
a number of subdivisions; among which are women
in industry, industrial relations, and self-insurance.
She has a division of industrial hygiene, and sev-
eral, 10 or more, employment agencies throughout
the state. You will see, however, that she has no
voice aside from, the State Fund that relates to
the compensation of injured workmen.
Now, this is no small matter. In 1929 there were
199,035 injuries reimrted. In that same year there
were held in the state 523,604 hearings. They dis-
charged about that many cases from their calen-
dar that year. Of course, some cases go on from
year to year before they are finally closed, but
she has averaged 5 hearings in every 2 cases. I
will leave that for our discussion to bring out —
why there should be so many hearings. The admin-
istration of this Act and the paying of the au-
thorizations allowed amount to more than $32,-
000,000 in our state. When a matter so extensive
as that presents itself, in which the crucial point
is the medical examination and report, it does
seem to us that medical men should have a more
direct relationship to administration of that part
of the law. Our relationship at the present time
is limited to her employees. She has physicians
employed to assist with the hearings. They have
in the year 1929 submitted a report of the medical
division which occupies just 1% pages of this
small book.
As compared with our Department of Health,
the Department of Labor in its medical phase
seems very poorly administered. One wonders
whether it is not time that we take a greater in-
terest and see that we get an opportunity to help
contribute something to the operating of this
law.
In your states, are the men who do industrial
work selected in any particular way, or is it purely
a matter of voluntary choice?
Dr. Morrison: Do you mean the Deputy Com-
missioners or the medical men?
Dr. Lawrence: The medical men.
Dr. Patterson: The most adequate and com-
plete surgical and medical care is given to the
employee.
Dr. Sommer: If he so desires, he can select his
own physician.
Dr. Morrison: But the law does not recognize
the insurance carrier. It only recognizes the em-
ployee and the employer.
Dr. Sommer: They sometimes employ physicians,
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
499
in our community, who are not members of the
county society and if they have cases requiring
hospital care from this compensation clinic they
park them in a private institution. Of course, we
get in our general hospitals a great many of their
injury cases and whenever they can in any way
get hold of them they take them away from those
physicians.
Dr. Lawrence: Do you have a similar system in
Pennsylvania?
Dr. Donaldson : Pennsylvania has an insurance
plan of its own that is subsidized by the state,
but most of the larger industries in Pennsylvania,
such as the railroads and the steel and coal com-
panies, maintain services for their own em-
ployees.
Dr. Lawrence: We call them self-insurers. How
about the selection of medical attendants by the
injured ?
Dr. Donaldson: That is not left to the choice of
the employee. It is the choice of the employer.
Dr. Lawrence: Does your law read that way?
Dr. Albertson: The law says that the employer
shall provide proper medical and surgical aid for
the injured.
Dr. Lawrence: So our 3 laws are about the
same.
Dr. Morrison: In New Jersey the compensation
is paid for by about 30 carrier insurance associa-
tions and they have found in an experience of
10-15 years that, because of allowing physicians
chosen by industries to treat their cases, losses
have become so enormous that they are coming
to the conclusion themselves that it will be cheaper
to have the physician chosen either by the em-
ployer or the employee himself than to keep on
with the present system ; that under the present
system they are paying for long periods of disa-
bility and greater amounts for permanent disa-
bility, because of treatment by incompetent physi-
cians.
Dr. Lawrence: You mean the employer in this
group appoints the physician, or the insurance
carrier ?
Dr. Morrison : The insurance carrier appoints
the physician.
Dr. Lawrence: And they are not satisfied with
that and think it would be better to have the in-
jured employee select his own physician?
Dr. Morrison: Yes.
Dr. Lawrence: The question suggested by Dr.
Sommer might well be discussed at this time. He
referred to the fact that patients are placed in
general hospitals and moved at times without good
reason. Do the hospitals charge the insurance
company a particular rate for compensation cases?
Dr. Sommer: They charge the regular ward rate.
The insurance carrier will only provide for regu-
lar ward rates. However, they will sometimes
provide special nursing services and private room
for an individual patient. I think that depends
upon the man who insures. If he has influence
enough with the company they will provide most
anything. I have had one patient, who was very
badly burned, for whom they provided special
nursing, private room, and took care of him for
more than 2 years, paying my bill also.
Dr. Lawrence: Does this same condition hold
in Pennsylvania?
Dr. Donaldson: They make provision now for
only 30 days’ care and $100 limit. YVe have hopes
of increasing both of those 50%. There is much
dissatisfaction all over the state about services
rendered to individuals who are necessarily in the
hospital longer than 30 days. There is provision
made for adjustment but adjustment is required in
each individual case. That is true also in the
other states.
Dr. Morrison: In our state the statutory pro-
vision is only $50 for medical and surgical fees.
That does not include the hospitalization. And we
have a gentlemen’s agreement with the carriers
by which the physician will' notify the carrier that
his bill is to be in excess of $50 and then the bill
is submitted and if the insurance company thinks
it excessive can refer it to a medical commission,
which we have in each judicial district of the
state. If the commission reports that the bill is
fair, the company pays it without further ques-
tion.
Dr. Sonvmer: I have attended a lady with a frac-
tured hip who has been in a private room of our
hospital for months. By some special arrange-
ment they take her occasionally before the Board
and give her a hearing and extend her time. Or-
dinarily, you would not think she should be 8
or 9 months in the hospital for a fractured hip,
but they are as a general rule quite liberal. I
think, too, they take into consideration many fac-
tors which we ordinarily would not consider. In
this case they have just extended her time and her
compensation.
Dr. Hagerty: Is not that provision referred to
by Dr. Morrison really more than a gentlemen’s
agreement ?
Dr. Morrison: No, it is simply a gentlemen’s
agreement.
Dr. Reik : I think it is written into the Act that
the physician must give notice if the charge is
likely to extend beyond the $50.
Dr. Lawrence: I know that we are not limited
by statute in this state in regard to the amount
of our fees, and our limitations come from in-
spectors whom the carriers employ and they may
interfere with the treatment or care of a patient
at any time, it seems. They may take him from
one physician to another or from one hospital to
another. We get quite excited here about what
we call “lifting cases”; this is done so extensively.
Cases are lifted, I am told, from! the far end of
Dong Island and brought to New York to be treat-
ed, or from Albany to Syracuse, with no reason
to exjject getting better care, so far as we can see.
Another difficulty that we have with carriers is
with regard to the payment of hospitals for ser-
vice. They insist upon putting patients in our
wards; and our wards are all operating under a
deficit. In some cases the ward rates are $2 or
$3 a day and our hospitals up-state during the
last year — several very reputable hospitals — stated
that they could not operate at that rate, that it
cost $5.80 a day for their patients in the ward
and when they did not get those rates it resulted
in a contribution of the local charity to those in-
surance carriers. So, many hospitals are refusing
their wards to compensation cases and are insist-
ing on a semi-private ward for such cases, where
they can charge a rate that will equal at least the
cost of carrying that patient in the hospital. The
insurance companies, especially the State Fund,
up-state object to that method but we are grad-
ually getting ourselves together and insisting upon
it. The administration of our Public YVelfare Law is
aiding us on that score. The state has wards under
that law and they are the people who heretofore
were carried as charity patients in the hospital, and
as charity patients of course they had a claim on
the community, but now, under the Welfare Act,
they become the wards of the state and there is no
particular reason why a community chest should
raise money to pay for expenses of a State ward
when the state has made provision to have that
500
JOURNAL OF VUE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
case cared for. It is our hope that we shall finally
get an understanding by which compensation cases
will pay their way in the hospital as though they
were private cases, not of course as if they were
millionaires, but as private patients able to pay.
Dr. Sommer-. Our local hospitals are not com-
plaining of rates. With us they seem to welcome
the compensation cases. We operate our insti-
tutions, of course, much more cheaply than you
do in New York State.
Dr. Morrison : There was some objection at first,
but the insurance companies are taking care of us
now all over the state.
Dr. Sommer : I think the carriers are dealing
very fairly with us now. The medical officer in
charge of the rehabilitation clinic acts as an ex-
pert and decides upon the degree of disability.
However, the man does not have to accept that
advice; he can obtain an outside physician and
have him certify to his disability and, depending
upon the standing and character of the physi-
cian he brings in, the commission takes consider-
ation of that and he may have his time of disa-
bility extended. Moreover, they settle upon a basis
of each particular injury, and if there is a residual
injury there may be a question of how much per-
manency there will be to the injury. These cases
may be re-opened within a certain time limit, for
adjudication. That is at the option of the em-
ployer as well as the employee or the insurance
carrier. I think our law has worked very well in
the main but it has met with some opposition.
For instance, an insurance carrier will enter into
an agreement with the medical officer to have him
care for a particular patient, and that is where we
have trouble, but we hope to change that and pro-
vide for full-time officers who will no longer be
allowed to do private practice.
Dr. Lawrence-. Do you mean by the medical
officer the physician in charge of the rehabilita-
tion clinic, and who acts in the hearing, or who
is appointed by the state to preside over the
hearings?
Dr. Morrison: The referees have the power to
select physicians to conduct the examinations at
headquarters.
Dr. Lawrence : That is done in about the same
way here.
Dr. Morrison: Dr. Lawrence referred to the
great number of hearings in each case. We have
had the same condition in New Jersey, and es-
pecially around the larger centers there has arisen
a system of racketeering among the physicians
and lawyers solely for the collection of fees — by
persuading the commissioner or deputy commis-
sioner to have a series of adjournments and every
time they appear in court they charge from $25
to $50. We had to put a time limit on that. We
now have an unpaid commission appointed by
Colonel Blunt, the Com|missioner of Labor, mak-
ing a study of the compensation law and its
administration in the state. We have been study-
ing the matter for a year and are about ready to
submit our report. We have a time limit during
which an application for a hearing can be made
and if the applicant does not appear upon the
date set for him the case is to be dismissed, un-
less he subsequently makes another application.
That, would bar hundreds of cases. Then the
deputy commissioners are instructed to be very
careful and insist upon adequate reasons for any
adjournment. If the case is set for today it must
be tried today and will not be set aside merely
on the request of a lawyer.
Dr. Lawrence: Now it seems to me — and I put
it as a suggestion for discussion — that the Depart-
ment of Labor and the physician who treats the
case are too remote from each other, that there
should be a more direct relationship. It seems to
me that one of the reasons for adjudication is that
the department or the carrier is taking advantage
of the lack of understanding or jumper recognition
of the physician who treats the patient. For in-
stance, I have knowledge of many men in this
state who rarely have any of their bills disputed.
They treat a patient and, just as Dr. Sommer has
said, I know men who have carried cases for an
unusual length of time; the patient needed the at-
tention, of course, and the bills were paid with
no argument whatever. On the other hand, I know
some men, who are just as honest and sincere as
they can be, who have every bill disputed and
have their office 'fees reduced by 25 to 50%. If
they want more they have great difficulty getting
it from the insurance company. The insurance
company, after a bill is submitted, will frequently
send back a statement that so much will be paid
and send the check along, making their own re-
ductions at the time. These physicians have no
support, nobody at court to protect them, and
therefore accept this reduction and the insurance
companies have found the method so profitable
that they continue its use.
Dr. Morrison: If your State Society will secure
this gentlemen’s agreement such as we have, and
the appointment of physicians to examine doc-
tors’ accounts, that will be done away with. It
has been working with us for 7 or 8 years.
Dr. Lawrence: I feel that if we had some in-
termediate positions filled by physicians that such
things would not need to occur. We had some
dozen or more years ago a similar situation with
regard to public health. The individual physi-
cian who did public health work was not recog-
nized and usually his work was considered wrong.
Others would duplicate it, or his field was invaded
without consultation, and so we developed here
a very nasty feeling toward public health work.
Machinery was established later which brought a
direct contact between the practicing physician,
the district state health officer and the commis-
sioner, and communications went back and forth,
instructions were carried along, so that at the
present time the average practitioner does not feel
any hesitancy whatever in taking care of com-
municable diseases. He knows what is necessary
to satisfy the State Department and the State De-
partment does not have any nervous feeling either
with regard to the practitioner. Communicable
diseases are reported, and not always is the diag-
nosis checked by the health officer; it is simply
accepted. I believe if we had more complete ma-
chinery between the physician and the carriers
their diagnoses would be accepted, their statements
believed and their bills paid as they should be.
I think Dr. Morrison’s statement with regard to
the Advisory Board is exactly a justification of the
point I am trying to bring out.
Dr. Morrison: We have had that Board in satis-
factory operation for about 7 years. It was brought
about through the State Medical Society.
Dr. Reik: I think we should explain that the
smooth working of that law in New Jersey is
largely due to the Commissioner that we had and
to the machinery that was then established, for,
as you have learned by the narcotic and prohibi-
tion laws, rules and regulations established for the
enforcement of the law are more important than
the law itself.
Dr. Morrison: I think our agreement was made
by Dr. Eagleton prior to Commissioner McBride’s
appointment.
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
501
Dr. Reik: After the first Commissioner’s death,
Dr. McBride was made Commissioner and he fur-
ther developed the work that Colonel Bryant had
started, and through his service of 7 years the
rules and regulations developed in the department,
plus the fact that he went through the county
medical societies teaching the doctors their re-
lation to the laws, have brought about much
smoother working. Also, the judicial district rep-
resentatives who pass upon bills have helped
smooth the way between the physicians doing the
work and the employers and carriers.
Dr. Lawrence: How is this Advisory Board or-
iginated ?
Dr. Sommer: One man represents the profession,
one the department and one is elected through
the insurance carriers.
Dr. Lawrence: Who selects the physician?
Dr. Sommer: The county society. As a matter of
fact these boards do not have many cases to con-
sider because any man who has a dispute knows
whether his bill is just or not and it is seldom
that a bill is brought up before that committee.
Dr. Hagerty is on .the Board of Essex County and
he can tell us that it has not had a great deal
of work to do.
Dr. Hagerty: I was appointed when we had no
rules or regulations laid down for us. I think in
justice to the carriers I might say that we had
as much trouble with the doctors as with the car-
riers. The work was new and some doctors saw
a chance to get big fees and were charging large
fees for trivial work. That was one of the un-
pleasant features about the work. For instance,
a man would have to be put in plaster and the
doctor would go in every few days to see the man
and it caused considerable trouble. But after our
conferences our judgment in the matter was ac-
cepted and the matter was settled amicably and
the work went along very well.
Dr. Lawrence: How was the physician ap-
pointed?
Dr. Hagerty: The appointment was received
from the county society to which the man be-
longed.
Dr. Lawrence: There is more than one county
in your district?
Dr. Hagerty: Yes.
Dr. Lawrence: How do you determine which
county he shall be appointed from?
Dr. Hagerty: I do not know except that Essex
is the largest county in our district and I think
the others looked to us for that appointment.
Dr. Lawrence: He contributes his services?
Dr. Hagerty: Yes.
Dr. Sommer: I know in our judicial district the
committee has very little work to do. I think once
the profession realizes that physicians will be
checked up they will be much more careful.
Dr. Lawrence: Do you have opportunities to
increase the requests of certain physicians as well
as to decrease them?
Dr. Hagerty: Often they failed to notify the in-
surance companies that a case would need longer
treatment and we would take that into considera-
tion. This provision that Dr. Morrison has men-
tioned was written into the act, that is, the car-
rier must be notified that the condition will last
longer and that more money than $50 is needed.
Before that was done the Advisory Board decided
tvhether the bill should be paid and our recom-
mendations were accepted.
Dr. Morrison: There has been also another cause
of complaint. The carriers’ plea was that doctors
did not submit satisfactory bills. For instance, a
man has a burned hand and every finger has to
be dressed; the doctor sends in a bill for $3 or
$4 for a dressing. The companies will cut that
down to $2 right away. But if he specifies that
it was an extensive burn necessitating the dress-
ing of each finger separately the bill would be
paid.
Dr. Sommer: You do not want to render a lump
sum bill to insurance carriers, for they will com-
plain about that. But, if you itemize, and send
even a larger bill, it will be paid; that is an inter-
esting fact.
Dr. Reik: The principal complaints at the pres-
ent time are; first, a failure to notify the insur-
ance company that the bill will amount to more
than $50; and secondly, the failure or refusal to
render an itemized bill. Those are the 2 main
complaints.
Dr. Lawrence: The next point I want to bring
out. is that in our state the Department of Labor
limits its interest almost entirely to disputing the
amount of compensation. So far as I am in-
formed, our Department of Labor is limited in its
constructive work with regard to injuries and oc-
cupational diseases to the issuance of a small
journal, 4 pages once a month. Usually, half of
that is taken up by description of a particular type
of machinery in some factory, or some scheme of
ventilation, and it only goes to a limited number
of people in the state, usually, I believe, to physi-
cians who are employed by self-insurers or work-
ers in the Department of Labor. No effort is
made by the Department to bring the physician to
a better understanding of industrial injuries and
occupational diseases, the value of which was so
beautifully demonstrated in the Army. Every man
went to war, I think, feeling that he would be as
good a doctor as the next fellow, that he could
treat a gun-shot wound, or this or that, but he was
not there long before he found there was a lot he
had to learn. And those men coming back have
added more to the constructive study of injuries
and to the advancement of the care of injured
workmen in our state than was learned during all
the years that the department itself has been in
existence.
Dr. Morrison: One of the reasons why your de-
partment's chief function seems to be to limit the
amount of mloney paid for compensation of in-
jury is the fact that you have a State Fund. If
your insurance was all carried by business con-
cerns you would not have so much of that trouble.
Dr. Lawrence: In any of your departments, is
there any constructive interest being taken in the
injured men?
Dr. Morrison: Yes, the basis of the law in New
Jersey is the interest of the employee.
Dr. Lawrence: The thing I have in mind is this:
Take the common head injury. Does the Depart-
ment of Labor make any effort to get at the physi-
cians who are doing industrial work and to keep
them abreast of the times concerning the treat-
ment of head injuries?
Dr. Morrison: No.
Dr. Lawrehce: Last year we made it a special
point at our branch society meetings to discuss
head injuries, and it was one of the most inter-
esting subjects that we had at our conferences.
Dr. Morrison: That is one of the duties of our
state societies. They must explain that industrial
surgery is a branch of general surgery, that it is
almost another specialty, and the ordinary family
physician is not always prepared to take care of
these cases. We must recognize the men who are
making this .a special line of work.
Dr. Lawrence: I will agree with you in part but
we did not solve our public health problem in that
302
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
way. The public health department made it a
point to see that the doctors were getting an op-
portunity to know the differential diagnosis of
chicken-pox and small-pox, of measles and scarlet
fever and other things. They instituted regular
methods of instruction, giving the physicians an
opportune to get that information if they wanted
it. I think the Department of Labor has a similar
obligation to the physicians who are willing to
take care of injured workmen.
Dr. Reik : Don’t you think a large percentage of
the profession would resent instructions of that
kind coming from a lay organization?
Dr. Lawrence'. Yes. It should have a medical
advistory division that would take care of the
medical work.
Dr. Morrison: Why doesn’t the state society
recognize industrial surgery and teach its mem-
bers?
Dr. Lawrence : Even that would be limited in
its extent.
Dr. Morrison: But it at least would be accepted
by the physicians without resentment.
Dr. Hagerty: The profession would come to
recognize that. In St. Michael’s Hospital, with
which I am connected, every case of head injury
is referred to the head department with consult-
ing head-surgeons. When it is found that the
patient has not a fractured skull he is sent back
to the general surgeon but all cases of head injury
are referred to the department of head-surgery
until it is determined that there is no head in-
jury.
Dr. Lawrence: Of course, the problem is not
limited any more to surgery. There are the occu-
pational diseases. In New l'ork State there are
many diseases and conditions as difficult to
diagnose as the communicable diseases. There are
the different types of poisoning, and then there
are abrasions, the asthmas, and various pulmonary
troubles. I may be wrong but I do think that
the Department of Labor should be in a position
to assist the medical societies in helping a man to
get instruction up to the minute on conditions that
are to be treated. We raised this question in a
group here in New Y'ork City one day in regard to
handling just a broken bone. It was demonstrated
that appliances could be created that would be
very effective in holding bones in place and some
very elaborate machinery was devised. There are
certain types of industrial injuries, or certain
groups of injuries, broken bones, for instance,
that occur more frequently than others and cer-
tain physicians who see many of those cases have
devised improvement in the manner of handling
them. The compensation people are acquainted
with that and they get the notion of what such an
injury ought to be allowed in compensation. Well,
a man up in the woods who has a similar injury
does not have the advantage of this man’s exper-
ience down here and he treats it in his own way.
The result may be that it takes him twice as long,
and then, maybe, it is not as satisfactory.
Dr. Albertson: I know that it is not correct. I
know, personally, that we have in our district
many men who treat fractures and they may take
longer to rehabilitate their patients than the men
in the cities take. The way the army has brought
out the method of treating fractures is mostly a
myth. I will admit, frankly, that there are some
Improvements but I happen to come from a com-
munity that has both the metropolitan and an
urban condition, and I happen to see patients with
both classes of men, and it is often surprising to
me — the result which a doctor will get in a coun-
try farm house where he has few or no modern
appliances but treats the fracture in the way he
was taught to do years ago. I am thinking par-
ticularly of fracture of the femur. I have seen
many of them treated in a farm house with won-
derful results, and without the use of an x-ray
apparatus. I am not advocating this as the best
thing to do, but I am bringing out the point that
it is done with good results.
Dr. Lawrence: I grant the exception. I was
speaking of the principle.
Dr. Albertson: The matter of time for rehabili-
tating a fracture or a head injury, particularly in
compensation work, is based largely on the repu-
tation of the physician. If he is anxious to do
good work the company will usually take the
right attitude toward that man. If they find an-
other man who is dragging his cases along they
soon know that and adjust his bills accordingly.
Dr. Lawrence: But a man who has had ex-
perience is pretty likely to have advantages in
the treatment of industrial injuries over the man
who has but little experience, and would it not be
wise to have the experience gathered by those
men who have many cases transmitted in some
way to the other men?
Dr. Albertson: Generally speaking that is true
but there is a great deal of superspecialism today.
We are specializing in everything. There is ad-
vance being made in medicine and surgery and
particularly along the line of industrial surgery
all the time. There is a chance for everybody to
learn. But I am satisfied that most of those
things should be thoroughly tried out and proved
before they are given out to the general prac-
titioner as adopted facts. I believe, arid I think
the industrial surgeon will bear me out, that there
are too many men who have gotten an idea that
certain forms of plaster splint, for instance, are
adaptable to all kinds of fractures and very many
serious results will be shown in the hands of men
who do not know how to use plaster.
Dr. Reik : I think we have lo'oked upon the point
that you make regarding education of the pro-
fession as an obligation of the profession to itself,
and we are covering that, in part at any rate, by
arrangement of our programs at the state and
county medical society meetings. In the annual
state society meeting, for the past 2 years, 1 ses-
sion has been devoted especially to industrial
medicine. For instance, at the last meeting there
were 2 sets of papers, one that started with in-
juries of the eye and special organs, and the other
dealing with fractures in general, skull and long
bones. We invited selected men to prepare those
papers, and invited in to discuss them experienced
physicians and also representatives of the Labor
Department and of the insurance carriers. Those
discussions practically amount to a carefully pre-
pared dissertation on the whole subject of in-
dustrial medicine. I happen to remember it be-
cause we have been publishing the proceedings in
the December and January Journals. At times we
have touched upon occupational diseases, and the
April Journal covers the question of lead poison-
ing, including 1 paper from a man who has de-
voted his attention largely to medicolegal affairs
and he tells us the legal aspect of occupational
diseases. We have assumed that education of the
profession in regard to this matter belongs to us
rather than to the Labor Department, but I see
no objection to having the said department aid
in the matter and I think it should be glad to do
so.
Dr. Lawrence: Did you not have the same feel-
ing at one time regarding Public Health?
Dr. Reik: I think I have it yet.
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
503
Dr. Lawrence: In Pennsylvania they rely a good
deal on their Secretary of the Public Health De-
partment for instruction and assistance in develop-
ing' public health work, do they not?
Dr. Albertson: Oh, yes indeed.
Dr. Lawrence: Your public health work in New
Jersey is largely under a lay department, is it
not?
Dr. Reik: At the present time the Commissioner
is a layman.
Dr. Sommer: Ours is an industrial city, of
course, and we have industries in which poison-
ings were common at one time. Now they are
comparatively rare. In the pottery industry we
have practically no lead poisoning occurring. The
methods of manufacture have changed so much,
there is less hand labor, and more casting and
machine labor. The American steel and wire mills
have not for years had such a thing as lead poison-
ing. Until recently a case would occasionally oc-
cur. In the process of heating the wire there is a
vaporization of steam and the workers would in-
hale the steam and get lead poisoning.. Now, the
only types of lead poisoning we see are due to
carelessness of some individual who takes up
painting as a side line or in the home. So far as
the industries are concerned, these cases have
practically disappeared.
Dr. Morrison: There has been called to the. at-
tention of our Commission the fact that there are
at present pending in New Jersey suits for lead
poisoning_ amounting to $9,000,000. All of these
are in the hands of racketeering groups of physi-
cians and lawyers, and the injured claiming com-
pensation are negroes or Portuguese. It has be-
come so extensive that the men engaged in such
industries in New Jersey pay $900 a year per em-
ployee in insurance to protect themselves.
Dr. Sommer: I can only speak for local condi-
tions. It has practically disappeared in my dis-
trict.
Dr. Morrison: Speaking of instructions, in ad-
dition to what Dr. Reik said about the program
of our state society, we have 2 groups of Post-
Graduate Lectures offered to the county societies,
that are given by men connected with hospitals
and colleges in Pennsylvania and New York. Be-
sides the elective courses in medicine we have one
in minor surgery, and that concerns practically
all sorts of conditions that are treated under com-
pensation. Our physicians are thus informed how
to manage those cases.
Dr. Lawrence: How do you give that informa-
tion?
Dr. Morrison: We are giving the information
through lectures in our Post-Graduate Courses
offered by the State Society.
Dr. Lawrence: We have in this state, of course,
an Industrial Surgeon’s Association but the mem-
bership is largely composed of men who are full-
time surgeons in industry. There are quite a num-
ber, probably 40 or 50, at these conferences which
are held twice a year and the sort of things I
have been talking about are discussed there, that
is, injuries or conditions that frequently arise in
industries. Methods of treatment and the newer
attitudes that are being developed with regard ^to
treatment and care of such cases are brought out
at these conferences. We have thought it very
valuable, but the average physician did not go
to the conferences.
Dr. Reik: I want to interrupt the meeting to in-
troduce Dr. Snedecor, of Hackensack, New Jersey,
and to offer him the privilege of the floor in order
that he may take part in the discussions.
Dr. Lawrence: We are glad to welcome you,
Dr. Snedecor, and trust you will take part in our
discussions.
My next point is on the other side of the picture.
The Department of Labor people make no con-
structive contribution to the problem but they do
sometimes encourage destructive criticism. Last
year they smiled very favorably upon and helped
to give expression to, if they did not definitely
organize, the investigation of industrial clinics in
this city and they unearthed what they considered
many very deplorable conditions. They offered some
legislation that would correct the conditions which
they found, unsanitary offices, places where only a
nurse was in attendance, and where physicians
treated patients by merely looking at them, and
many cases of neglect. I do not doubt that all of
this was based on fact but they picked out cer-
tain places to condemn, as almost any one can
do in certain neighborhoods. It seems to me that
it is only fair if we listen to their criticisms of
that character we ought to expect from them some
constructive aid. Our Department of Labor has
contact with employees and with industry, but no
satisfactory approach to medicine.
I consider the next point of great value. How
does the general care of those suffering from in-
dustrial injuries or occupational diseases compare
with the general practice of medicine at the pres-
ent time? Has not a great deal more advancement
been made in the general practice of medicine in
the last quarter of a century than has been made
in the handling of occupational conditions?
Dr. Albertson: The handling of occupational
diseases is comparatively young, perhaps since
1915, but I will venture to say that the advance
made in handling industrial injuries in the past
15 years has been greater than in the 60 years
previous. It certainly keeps abreast of the ad-
vance in g'eneral medicine.
Dr. Morrison: I agree with Dr. Albertson.
Dr. Lawrence: A very prominent surgeon has
said that the general practice of medicine is 10
years ahead of the methods of caring for indus-
trial conditions, and he is an industrial surgeon.
He is an up-state man and a general surgeon but
does a lot of industrial work which is referred to
him. Dr. Albertson has suggested that in referred
work he sees only the worst cases, which may be
true. I am glad to get the reaction from your 2
states and I will balance that with the opinion of
the man from up-state.
Dr. Albertson: It would be interesting to get the
reaction from several viewpoints, say from 10
general practitioners in different localities, 10 in-
dustrial surgeons, and from general, surgeons in
10 different counties.
Dr. Lawrence: That would be the way we should
go about it. There is another phase with regard
to this. I think that our treatment or care is not
entirely that which the physician himself would
select in many instances but when he is treating
an industrial case he does about what is suggested
to him or what he has found from past experience
will be acceptable to the insurance companies. For
instance, when ultraviolet lamps came on the
market the industrial surgeon was the man very
generally who bought the lamps.
Dr. Morrison: Plus the osteopaths and the cult-
ists.
Dr. Lawrence: Yes, but among the medical men
connected with the insurance carriers it seemed to
be the thought that an open injury especially was
bound to heal with a limited motion unless it was
given a certain number of treatments with the
lamp. We made an investigation and got the car-
riers to testify and there was just one carrier who
504
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
said there are probably some advantages to be de-
rived from the use of the lamp. All the others
said it had no advantage, and yet the lamp is still
used to a great extent. Some doctors have nurses
in their offices who give treatments with the lamp
for $2 or $3 each and extend the treatments in-
definitely.
Dr. Albertson : All of these subjects are too large
to take any one’s individual opinion. The thing
that would be of advantage is the opinion of many
men in different localities.
Dr. Lawrence: Another point: I do not know
what the legislation in your several states is with
regard to advancement of the number of compen-
satable conditions, but in New York State we are
very likely this year to enact legislation that will
remove this enumeration of conditions and simply
let the law read that a person shall be compensated
for any injury or incapacitating condition arising
out of occupation. That may mean because of the
apparatus or because of the work the person is
doing. Now, if that is passed, there is a porton
of it which says that a man who is discovered to
be incapacitated from an industrial occupation
which may have originated in a previous employ-
ment shall have his compensation divided between
the several employers. In other words, if a man
is working in a woolen or porcelain factory, and
has worked during the past 25 years in 5 or 6
other factories, and comes down with pneumo-
coniosis, that enormous and definite disability,
they will have to go back and share that com-
pensation among the various employers if the pre-
vious employers cannot prove that he was in
splendid condition when he left them, or if the
present employer cannot prove also that he did
have some such condition when he came to work
for him. As I have pointed out to the Depart-
ment of Labor, this will mean that every work-
man when he starts to work will have his card,
and when he is leaving and seeking employment
elsewhere his card will follow him, and different
notations will be made of the findings. He may be
examined by another physician G months later who
will add another note. When he has reached the
age of 35 or 40 no one will want to employ him.
The key position for this is the physician in his
medical examination. We will be the goats every
time. You may not be threatened with such legis-
lation but we are.
Dr. Donaldson : All labor legislation seems to or-
iginate in New York State.
Dr. Albertson: I am interested to know what
the reaction of your State Medical Society is to
that.
Dr. Lawrence: We are opposed to it because we
know that it will encourage malingering and poor
practice.
Dr. Albertson: Not only that, but if that goes
through it will be the beginning of state medicine.
Dr. Lawrence: Certainly. This would not even
exclude the office force. A man might go home
and have a terrible headache. He may have been
out the- night before but if he develops pneumonia
it will be blamed on the poor ventilation in the
room.
Dr. Patterson: Does that mean that all the
sclerotic conditions can be ascribed to occupational
disease?
Dr. Lawrence: It depends on what the examin-
ing physician says.
Dr. Patterson: If a man who is engaged in
laborious occupations for a number of years de-
velops arteriosclerosis might he be said to be
suffering from occupational disease or a series
of occupational effects?
Dr. Lawrence: So far as the law reads, that is
right.
Dr. Patterson: That is a very dangerous thing.
Dr. Reik: If we expect employers to compensate
laborers for what happens to them while engaged,
then requiring examination of laborers when they
enter upon employment is inevitable. So, is it not
easier for us to prepare for that than to let the
Labor Department put over such a bill as Dr. Law-
rence talks about now. If it comes from private
interests it will surely be wrong.
Dr. Albertson: May I ask to what extent your
carriers in New York and New Jersey require
that the employees be examined before accepting a
position ?
Dr. Lawrence: So far as New York is concerned
there is no general demand for that at all.
Dr. Reik: No, but a great many employers are
doing it all the same.
Dr. Albertson: So many employees in Pennsyl-
vania had old hernias which had to be fixed that
now some industries will not accept a man for
any position until he has a physician’s statement
that he has not a hernia at that time, and it must
usually be some physician in whom they have
sufficient confidence.
Dr. Lawrence: I think that is a pretty general
practice among our self-insurers. They do ex-
amine their employees, and in some instances give
them periodic examinations, but where the insur-
ance is carried by the State Fund or by a carrier
they do not examine them.
Dr. Reik: Wouldn’t you want to insist upon the
initial examination if you were an employer?
Dr. Laivrence: Y'es, I would. We have for several
years been following a suggestion made by the In-
dustrial Survey Commission, appointed by the
legislature, upon supporting a bill which would
create a Medical Advisory Council in the Depart-
ment of Labor to balance with the ones already
there representing labor and industry. Last year
we got it through one house and up to the final
reading in the other, when the Commissioner stop-
ped it. She promised me a conference, which she
has not yet granted. The only objection she
stated was that she had already allowed herself to
be too liberal in taking public advice. I know,
however, that she would not give this as a real
reason.
Dr. Morrison: One of the recommendations of
our commission is that a referee commission of
3 physicians be appointed, to be at the call of
the commissioner, the cases to be examined by
this Advisory Commission and its findings accept-
ed as final. That will solve a great many diffi-
culties in the conduct of these cases.
Dr. Lawrence: I think if we had a medical ad-
visory committee composed of 5 physicians, 3
nominees from the State Medical Society, 1 from
the State Homebpathic Society and 1 from the
State Osteopathic Society, it would be helpful.
They could with profit study and classify injuries
and diseases arising from occupations.
Dr. Morrison: They will not do this unless they
are paid for it.
Dr. Lawrence: It would be worth the money we
would pay for it when we have so many men in
industry liable to certain types of disease who will
come up for compensation at some time or other
if we pass this other measure. And the earlier
we know what these things are the better. At
the present time if there is a community in the
state where health conditions are not good the
Department of Health develops that fact. There
is no longer doubt as to where you will locate with
your family because of the water supply, because
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
505
that knowledge can be gotten from the state. But
you can go into an industry and not know whether
it is a dangerous industry or not; there is no gen-
eral information of that character.
One point that industrialists have made at sev-
eral of our hearings lately, which is well worth
thinking about, is that they are leaving New York
State with their industries and going south be-
cause we are legislating too much up here in a
haphazard way. The industries are going south,
some few into Pennsylvania, because those states
have more liberal conditions than exist in New
York.
Dr. Donaldson: For a number of years legisla-
tion in Pennsylvania has been controlled by the
representatives of capital rather than by the rep-
resentatives of labor.
Dr. Lawrence: Our cotton mills have almost all
gone south and many other industries are leaving
us. If we had this statute we would be in a
position to intelligently do something.
I think this Medical Advisory Committee should
supervise the preparation of pamphlets of in-
struction regarding treatment and care of these
cases. The industrial surgeons issue monthly a
publication of their own, among themselves, and
I think the Department of Labor, through a Medi-
cal Advisory Board, should send to all physicians in
the state, at regular intervals, pamphlets or a
journal containing information regarding the
treatment and care of industrial conditions.
Then there should be private means for supply-
ing medical and surgical instruction for those de-
siring to engage in industrial work. We have our
large industrial clinics in New York and you per-
haps have them in other places. Why should not
facilities be made available there, just as they are
for general hospital work, for the man in the
smaller community so that he may inform himself
concerning the newer methods of handling certain
types of illness or injury? And I believe that a
Medical Advisory Board should take care of that.
There should be facilities for the inspection of
medical work in large centers by medical men.
That would sort of meet what New Jersey has in
its Advisory Board.
Dr. Sommer: When Bryant introduced the re-
habilitation clinics he had an advisory board at
each clinic but they did not seem to function prop-
erly, but once they got a medical man appointed
to do the work there was nothing more to com-
plain about. But, we selected the medical man
originally to take charge of the work.
Dr. Morrison: We have those rehabilitation clinics
in different parts of the state; I think there are 4
of them, and the plan is a monument to Dr. Mc-
Bride.
Dr. Sommer: Any doctor who sends a patient
to those clinics may designate the type of treat-
ment he wants given but under the law it must
be done under the Director of the Clinic.
Dr. Lawrence: Could the physician take the pa-
tient there and care for the treatment himself, and
then take the patient back home and care for
him?
Dr. Sommer: No! He could go there and see it
done but it is done in cooperation with the Direc-
tor of the Clinic who is responsible for the work
of the clinic.
Dr. Reik : Perhaps it should be made clear that
we have a double advisory system at the present
time. After Dr. McBride went out of office a non-
medical man came in as Commissioner of Labor
and he has appointed an advisory board, of which
Dr. Morrison is a member, that is separate and dis-
tinct from the district advisory boards handling
disputed claims.
Your scheme of a committee of 5 medical men
working in the Department of Labor to carry on
the instructive work for the medical profession
seems to me of doubtful value. I have always be-
lieved that if you wanted a thing well done you
should do, it yourself, and I think you will reach
your goal much quicker if such a committee is ap-
pointed within your medical society to carry on
this instructive work, because there you can as-
sure yourself of getting the best medical advice
for dissemination to the medical profession, and
you can arrange it much better than any group
appointed by the Department of Labor. And, you
will get it promptly, instead of waiting for legis-
lation and new appointments and starting a com-
mittee to work on something that it knows noth-
ing about. I think you would do more effective
work and reach your goal much more quickly by
education of the profession through the profes-
sion.
Dr. Morrison: And if you do it through the De-
partment of Labor you will be putting another
spoke in the wheel of state medicine.
Dr. Lawrence: I had thought that it would be
a step in the other, direction. At present our great-
est desire from the general group of men who are
doing industrial work is for the free choice of
physicians by the injured employee. Industry and
labor, I have been told recently, are both opposed
to this. We had thought labor was with us and
that they appreciated the advantages to be de-
rived from their own selection of physicians but
apparently wre were misinformed. Now, if we had
a medical advisory board we believe that we would
have an approach to the commissioner and an
opportunity to argue the question and possibly
secure our desires.
Dr. Morrison: Not unless the advisory board was
composed of medical men.
Dr. Lawrence: We nominate the man. That is
in the Bill. With reference to this free selection of
physician, I appeared at a hearing last winter and
although I was not thoroughly sold to it I put up
a pretty good argument. The industrial surgeons
and also the industrial carriers have had a num-
ber of conferences during the summer. One point
brought out by the average opponent of the free
choice of physicians is the fact that if a man is
injured in the factory he cannot go to his home
and have his family physician but he must select
some one nearby, and he will probably pick up
some one of the type of doctors who are posting
notices in our factories right along, so it would
be safer for the carrier to say who the physician
shall be. If, on the other hand, a man has
lead poisoning, why can’t he have his fam-
ily physician? There are, too, many other
conditions which might be treated better at
home. Why should he be obliged to go down town
and be treated by the physician selected by the
carrier? That was not brought out at the hearing
but I have thought it over a great deal since then.
I believe that in 3 out of 5 instances where a
physician is needed the family physican would be
the logical one to have.
Dr. Alberston: That is all true but it all goes
back to the same point we spoke of some time ago.
Dr. Morrison: The man who pays the doctor’s
bill will always demand the right to choose his
doctor.
Dr. Lawrence: That point I think needs a lot of
consideration. It leads up to an enormous prob-
lem in this state. It is also an enormous problem
of the Federal Government. The man wffio
506
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
pays the bill is not necessarily the one who
handles the money. In this state, at the present
time, it is the fad to have everything done by
State Aid, as though the state brought money
down as manna from heaven. They do not realize
that state aid means increased taxation.
Dr. Albertson-. The real argument is purely a
personal one. If you were ill, who would you
want to take care of you?
Dr. Lawrence : That is the very question I put
before the hearing in the Capitol. I said: “Gentle-
men, I leave it all to you. I only want to ask you
if, in leaving the chamber here, you should slip
and fall on a step, as one of the legislators did
a few months ago, and break a leg, do you want
to select your physician or do you want me to
do so?”
Dr. Morrison: I understand that your Public
Kelations Committee has secured from the car-
riers a promise to allow the employee to select his
own physician.
Dr. Lawrence: Yes, but those are only gentle-
men’s agreements.
Dr. Morrison: A gentlemen’s agreement can
carry you very far if it is lived up to. Our car-
riers say that they are getting worse results where
the employees choose their own physicians.
Dr. Lawrence: Our carriers have said the same
thing. It has only been tried for a few months,
so we really do not know what the result will be.
Dr. Morrison: We are watching that with a
great deal of interest.
Dr. Albertson : I have been interested in this
subject in my limited community since compen-
sation became a fact. Recently I talked with the
manager of the compensation fund in Scranton.
The State Insurance Fund has certain districts
in which it works and a man is appointed to
supervise each district. I said to him: “You in-
sure groups of employees and the employer selects
the physician. Other groups of people have a
choice in selecting their own physicians. What is
your experience in the relative length of disa-
bility in those 2 groups?” He said there was no
difference. That was very interesting to me. Of
course, that is only in a small community and
whether that would be- true in the whole state I
do not know. The doctors in that particular com-
munity have dealt for many years with industrial
conditions and when the compensation law came
along we had the same problem to deal with that
you had. They now treat these conditions in an
improved manner and I do not think we have any
trouble about the compensation. There is a sub-
ject I would like to take up sometime correlating
with this, and that is the matter of compensation
to hospitals both by the insurance carriers of
compensation cases and the compensation to hos-
pitals and physicians from accident insurance. I
think it is a very timely subject for this group to
discuss. You have in New York, a compulsory in-
surance covering automobile drivers?
Dr. Lawrence: It is hardly that. It is not like
the Massachusetts law. If a man has an accident
and cannot pay for the damages, he may lose his
license and cannot get it again unless he can give
assurance that in the future he will be able to pay
all the damages.
Dr. Albertson : That means that the man who
has any sense insures his car. There are more cars
insured than ever before but the difficulty today
is to collect your bill from those companies.
Dr. Morrison: In New Jersey last year we passed
a law providing that against any money indemnity
in accidents, except compensation cases (covers
all automobile accidents), the hospital bill shall be
a prior lien. We tried to get it to include the
physicians and nurses attending such patients but
did not succeed.
Dr. Lawrence: Can the hospital include the
physicians’ fees?
Dr. Morrison: No! We hope to get the law
amended later on. The year before our law went
into effect the hospitals lost $395,000 on account
of such unpaid-for patients.
Dr. Lawrence: One of our big hospitals is ser-
iously handicapped by caring for individuals
brought into the hospital with injuries, who have
received compensation themselves, and some even
have cashed their checks through the hospital,
but leave when their time is up without paying
their bills.
Dr. Morrison: One of our hospitals solved that
by having an attachment put on the patient’s
car.
Dr. Hagerty: May I express the hope that any
education to be given the doctors doing industrial
work will come through the profession itself and
not through any alliance with labor. We had a
very enlightening experience in Newark last year.
You might get the impression from Dr. Morrison
that our work had gone on very satisfactorily. It
has, but Dr. McBride’s office was subjected to
criticism last year and the press took up the
cudgels of labor. Dr. McBride, in self defense, ap-
pointed a committee and asked that his office be
investigated. The investigation was started by a
lawyer who was a very bitter fellow. There was a
point, however, on which he was right, that some
of the physicians were serving in a dual capacity,
serving both the employee and the carrier. When
Dr. McBride was convinced of that fact he
promptly suppressed the practice.
Dr. Morrison: The report of our commission
recommends that hereafter physicians engaged by
the state be not allowed to do any other practice.
Dr. Hagerty: They had been doing other practice
up to that time.
Dr. Lawrence: At one of our clinics men were
being examined and referred to another clinic for
treatment, and that clinic was conducted by the
doctor’s wife.
The meeting adjourned for luncheon.
After luncheon the discussion was continued.
Dr. William H. Ross presiding.
Dr. Ross: I will ask Dr. Snedecor to give us
some of his views on Councilor District meetings,
as I know he has given some little thought to the
subject.
Dr. Snedecor: The councilor districts in New
Jersey are really just beginning to function, as I
would conceive it, and we are rather looking to
Pennsylvania and New York for aid and advice.
As Councilor for one of the districts it is possibly
appropriate to open the discussion on the develop-
ment of such district branches and ask that you
enlarge upon some suggestions I may make.
We see a real need for such district conferences
in the growth of our medical societies, for the
very vital reason that organization is probably the
bulwark of the future for the medical profession.
Upon the medical oi'ganization during the next
few years there will be many stresses and strains
and if we do not ramify and integrate in order to
meet the problems we will regret it. Looking
back over the development in our own state so-
ciety, I thought of the great changes that have
occurred in the last 10 years. It has been a renais-
sance. Looking to the future, I think there will
be even greater changes because problems are
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
507
appearing that were never heard of before.. The
reason that medical organization has even been
developed to its present extent is due to the in-
dividual practitioners feeling the need for a repre-
sentative organization. When that came to pass
the real work in medical societies started. That
need, they say, is of greater importance today. They
are willing to progress further and take their
part in medical organization. It is also under-
stood that the private practitioner cannot speak
out in his own behalf without losing a tremen-
dous amount of prestige and protection which the
profession has at present, but through medical
organization we may' reach out to meet the prob-
lems of the future. Medical organization,
therefore, deserves a great deal of under-
standing and of scientific investigation in order
to insure its proper development. In our
state the Councilor District fits in between the
state and county societies, just as it does in New
York and Pennsylvania. We have a Councilor for
each district but up to the present his duties have
only been to look after local responsibilities, such
as malpractice suits, and report at the State So-
ciety’s Annual Meeting. The incentive for develop-
ing our district meetings was started in Trenton
last November, at the meeting of County Society
Secretaries and Reporters, largely through Dr.
Lathrope’s effort and his inducing Dr. Donaldson,
of Pennsylvania, to describe his state’s system.
It was then left to the individual districts to de-
cide the type and manner of association that they
would form. The First Distinct recently had a
meeting in Newark at which its 4 county societies
were invited to be present. Dr. Ross addressed that
meeting and the discussion which followed his
paper was lively enough to indicate that it was of
widespread interest. There was no business trans-
acted, however.
The Second District, of which I am Councilor,
has organized along a little different line which is
perhaps worth explaining. We met at Jersey
City and discussed our problems, the officers only
of each society being present. We looked over
the various needs that a councilor district might
serve, analyzed them, and decided that scientific
meetings would be of very little value, if not
superfluous, because we have so many of such
meetings during the year. We considered the
social aspects and decided that the men would
have to come from too great distance and their
problems were too diverse to make the meeting
a success unless we had a topic in which they
were all interested. We did conclude that the ad-
ministrative, economic and public health phases
need a district organization where we might cor-
relate our mutual suggestions, compare them, and
do some constructive work, carrying back to our
county society units what we had talked over, and
taking to the state society some of the problems
that we felt should be met there. The third phase
of possibilities is included in the topics that came
up for discussion at that conference. I will give
you these topics so that you may understand what
is in the minds of the second district men, what
they have on their program for the April meeting
in Hackensack to which all our 4 county society
officers are invited, and also our Delegates to the
State Society. (1) Legislation to obtain liens for
physicians in accident cases; (2) deciding how to
regulate specialism; (3) free school examinations;
(4) a definite policy to continue immunization
against diphtheria, in relation to doctors, school
boards and boards of health; (5) county society
publicity, supervision of free medical service, and
certification to county health units. These were
all live topics to the group and were assigned to
members to be presented at the April meeting. It
is hoped to get from that April meeting some con-
structive ideas to carry back to our own county
societies and to carry forward to the State Society
Convention. We hope in so doing to interest the
Delegates with a sense of responsibility of their
duties because in the past our experience has been
that some were not sufficiently interested in the
state society meetings even to attend them.
So, there are the 3 phases that we see in the
councilor district meetings. It is entirely experi-
mental with us at present. We are open to sug-
gestions and we see the opportunity to develop
the administrative, economic and public health
possibilities in the county societies, to interest
the delegates to the state society, to give them
a definite program to go to the state society with
in June, to rewrite our own constitution and to
give the councilors some duties to perform.
Dr. Ross: I think this is a mighty constructive
talk. ' I am not so sure but that the New Jersey
men, with the experience of the other 2 states
represented here, may quickly advance very far.
If we are not careful they will certainly outdis-
tance us. There is nothing more vital today be-
fore the profession than better organization for its
public service.
Dr. Donaldson: I feel like continuing the dis-
cussion because I am very much interested in
seeing what New Jersey will accomplish, having
paid me the compliment of asking me to represent
our society and go down to their society for a dis-
cussion of this subject last year. We certainly feel
a glow of satisfaction when we hear the program
that Dr. Snedecor has outlined and I believe it will
soon accomplish as much as we have in a great
many years. I was particularly interested in the
suggestion that they are going to invite the county
delegates to their state society to come and sit
in on their discussion and actually hear about the
problems before they go to their state meeting.
However, I was a bit surprised when Dr. Snedecor
said that they rarely attend the House of Dele-
gates to which they have been chosen. I am sure
they do not have so many interesting political dis-
cussions as we do in Pennsylvania or they would
not be permitted to be absent. We have a great
deal of difficulty on account of political influence
in having the same men come year after year
representing their county society, so that they
become a little too cognizant of their power and
strength, too well organized, and they are very
likely to keep down a discussion of the very sub-
jects the doctor has touched upon.
Perhaps I misunderstood you when you said you
would take up all of these problems at your meet-
ing in April.
Dr. Snedecor: They are to be presented briefly.
We would not expect to solve all of them.
Dr. Donaldson: I would caution you against
taking up too many of them at your first meeting.
I think you would do better to give careful thought
to attempting to solve 2 of them rather than to
give a mere smattering of consideration to a
dozen of them. I certainly am pleased to see that
the thing is going and that it is in such excellent
hands.
Dr. Reik: Dr. Donaldson might like to hear that
his visit to Trenton and the inspiration he aroused
by telling us what had been done in Pennsylvania
has led to this development in New Jersey. I
can tell him further that we have 5 councilor dis-
tricts, embracing in groups the 21 county so-
cieties, and all 5 have arranged for or held such
meetings since Dr. Donaldson’s visit. Having left
508
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
this to each district to decide what the course of
action should be, the first district, meeting- in New-
ark, with Dr. Ross as guest speaker, discussed
economic problems. Dr. Snedecor has spoken for
the second district. Programs for the third and
fourth are not yet announced although meetings
are being arranged. Down in the fifth district
they have arranged for an entire day’s meeting,
a combination of scientific and economic programs.
The afternoon is to be devoted to a discussion of
economic problems, they will then meet at dinner,
and in the evening there will be a joint meeting
of the Atlantic City Hospital Staff and the sev-
eral county society groups at the hospital where
there will be clinical demonstrations.
The start that Dr. Donaldson gave us has re-
sulted in unanimous acceptance of the plan and
an active interest in developing it.
Dr. Ross: In New Y'ork State no one knows
more about this subject than Dr. Overton. Per-
haps he will tell us something about the situation
in New York State.
Dr. Overton: For several years one of my duties
has been to attend each of the 8 District Branch
Meetings. I was interested in one of the western
states, I think Wisconsin, that in its constitution
one of the duties of the councilor is to act as an
investigator, as a peacemaker and as a censor.
The peacemaker seems rather a remarkable thing.
Mr. President, I presume that what you refer-
red to was possibly an editorial which I wrote
several years ago on the ideal district branch
meeting. These district branch meetings have
been held since the amalgamation of our 2 state
societies in 1906. There is very little said in the
constitution as to what the district branches
should be, so each district branch can do as it
pleases. All of the district branches except the
second, which includes Long Island and Brooklyn,
put on a scientific program. Possibly that is not
entirely wise because the business of the district
branches is administrative rather than scientific,
but everybody goes to the district branch meet-
ings. There will always be from 100 to 115 present.
In the editorial referred to, I made a study one
year of what I believe to be the important fea-
tures of the district branch meetings and I made
a composite program of these 8 meetings. In the
first place there is sociability, which is stressed.
Dr. Dougherty stresses the importance of socia-
bility and I, too, think it is extremely important.
There is the scientific end which is also very im-
portant although I think that New Jersey’s second
district is taking the proper attitude possibly re-
garding the scientific phase. We cannot put too
much in. The third phase mentioned was reports
from the different districts. The councilor was
to make a review of the work. In all the state
societies with which I am familiar it is the duty
of the councilor to visit the county societies and
find out what they are doing and to make a report
on that. Some of the districts do it very, very
well and when it was done well it seemed to be
quite a help. But, remember that each district
makes its own program and the leaders, the Presi-
dent and Secretary, are not always experts in the
state society work and have not a wide vision, so
that the program is not always carried out. Last
year our President did carry it out; he made a
study of what is going on in each county. If one
undertakes that, particularly in New York State
with its 60 counties, he will be a busy man. There
is an average of 8 counties in each of our districts
and to visit them all is not an easy matter. The
ideal district branch meeting it would seem, judg-
ing by the way the doctors take hold and show
an interest in the program, has a three-fold in-
terest— social, scientific and administrative — and
the coordination of what each district branch is
doing. The visit of the councilor to the different
societies is very valuable but I must confess that
the councilors do not carry this out more than
10-20% of the time.
Report . op Governor Roosevelt’s Commission
to
Devise a Public Health Program
Dr. Ross: I have no formal paper to give on the
the report of Governor Roosevelt’s Commission on
a State Public Health Program and I have attend-
ed so many meetings this month that I am getting
a little cautious for fear I may get them mixed
up, so, before coming here today, I put down some
notes which may help me.
The science of medicine is an advancing force.
There is no question about that. The relationships
of medicine are steadily shifting and they will
continue to do so. The changes are going on today
in government, in industry, and in all social con-
ditions. We have recently carried this gospel to
more than 100 groups of doctors. The idea of or-
ganization that we hold now is based entirely on
the understanding that the outstanding problems
of medicine are its public relationships, and also
on the understanding that the science of medicine
is perfectly secure; its phenomenal advance and
the momentum it has acquired during a course of
years is now so secure, its cultivation is so care-
fully looked after by the schools, so carefully
nourished in the laboratories of research and in
the scientific and organized meetings, that the
scientific part can rest for a time while we under-
take to bring up to that level our relationships,
and the organization of service for better avail-
ability of the science of medicine to the public
so that the present day scientific knowledge of the
prevention of disease and the conservation of life
may be brought within the reach of everyone.
That is really the problem we have. The problems
of health are summarized in this way. We should
have effective local health departments with a
qualified personnel. We must have more effective
service in the control of tuberculosis and cancer
and venereal diseases. I attended a meeting of
the Cancer Control Committee last night, and an-
other a week ago. and although I knew something
about it, the work that is starting is rather mar-
velous. We must have more comprehensive meas-
ures to reduce death from child-birth. It is a serious
matter that there are more deaths among moth-
ers in this country than in other civilized coun-
tries, and it is also rather appalling to find out
that those who have studied it most believe that it
is largely due to hurry.
We need better public health nursing. In some
counties in New York State we have 1 nurse to
over 500 people. We have also several other
minor problems. Last year, in May, the Governor
of this state created unofficial commissions to
study the administration of health in the state
and the adequacy of the laws relating thereto.
Nothing much has been done in the way of organ-
ization since 1913 and even up to that time there
was no real, definite organization. But, there have
been added to the law of 1850, when conditions
were vastly different, many very splendid pieces
of legislation.
This Commission appointed by the Governor is
made up of 14 individuals representing the widely
distributed interests in the state, including every
department of the state government that has any
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
interest in medicine. There were 8 doctors on the
commission. However, only 3 were actually in-
terested in medicine. Still, medicine has had a
very much bigger voice in this than it has ever
had before. Then, there were sub-committees ap-
pointed, subjects were assigned to each of the 14
members, and with the sub-committees there was
a total of 86 people working on this subject all
the time. A preliminary report was made to the
Governor recently, a report of 50 printed pages.
1 have some copies with me so that all of you
may have one. The preliminary report covers
the ground that involves some form mainly of
legislation. The final report will not be published
until next spring. It will be a large volume and
it is as comparable to the reports of the Child
Health Conference in Washington and the Com-
mittee on the Study of the Cost of Medical Care
as a state is comparable ,to a nation. The Gover-
nor has transmitted this report to the legislature
with a message, and a Bill was introduced this
last week into the Senate and the Assembly ask-
ing for the enactment into law of the recommen-
dations.
I would like to refer to one page of it. I have
told you that the membership of this Commission
so far as possible covered the various interests of
the state. It covered very specially the Depart-
ment of Labor. In that department industrial
hygiene has had less attention, perhaps, than any-
thing else. It concerns from 2,000,000 to 4,000,000
people. Now, the outstanding feature of this re-
port is that there is to be better organization, an
organization on a county basis with county boards
of health. I might say in passing that practically
every scientific organization interested in public
health in this state has endorsed this form of
organization.
The Commission has had regard for the econ-
omic situation. It has not undertaken to impose a
definite form of organization upon every county
in the state but has endeavored to set up a pre-
liminary basic organization and to permit each
county to work out its problems as well as it can.
Further than that, it has only insisted upon full-
time personnel in counties having more than 50,-
000 population, and those having 30,000 it will
bring under conditions of the Public Health Coun-
cil. In the latter counties it does not require
them to go to the expense of having full-time
officers but the state will assign one of its district
health officers until that county wants to take on
more work. Greene County said last night it did
not want to take advantage of this but wanted to
have a full-time man when establishing its or-
ganization.
The major recommendation is very constructive.
First, the county provides a health officer and
then the county is left to work out its own plans.
In cities of more than 50,000 they should have a
full-time health officer. Even New York City does
not have a full-time Commissioner of Health at
present. In tuberculosis problems the death rate
has been cut in half. There is a law in the state
requiring a sanatorium in every county, but it is
not economically sound and has never been car-
ried out; 27 counties have no facilities for treat-
ing tuberculous cases and this Bill carries with it
provision for the establishment of 3 district sana-
toriums in proper locations so that they will serve
counties not having such facilities; they are to
be built at the state’s expense and maintained, and
the cost charged back to the counties that use
them for patients.
We have no general venereal disease control in
this state, and a program is being developed for
509
that. At the same time, when we stop to think
that New York voted a $50,000,000 bond issue by a
vote of 6 to 1, and that $8,000,000 of that must be
spent to accommodate persons who will become
insane from syphilis in the next generation, it
really does become a great problem.
The division of Cancer Control built up about
the Institute for the Study of Malignant Diseases,
in Buffalo, which has been very largely supported
by the state, admitted last year 1800 people for
treatment. But that does not extend over the
state. Then we have maternal, infancy and state
hygiene, and the Bill has something to do with
all of these things.
I have spoken in 5 counties within a week, on
questions arising from this report, and find a
marvelous unanimity of opinion as to its construc-
tive value. The only question is the relationship
of the present health officers to the report, and
the Bill carries the provision that the present
local health officers shall become “deputy officers”
so that they shall be continued, only having to
come up to certain average standards.
Continued contact with organized medicine in
New York State this year, and with its component
county societies for several years, taking part now
in more than 500 of those meetings, conferences
and committees in the last 6 years, furnishes a
basis for a conclusion that I want to now state,
that the problems of medicine are not scientific,
for that part is being well taken care of as we
go along. The scientific end needs a minimum of
attention, but its relationships and the application
of its science to public service are the big
problems of the future. An opportunity to observe
these problems in 8 other states this year, and
hearing their discussions, shows a tremendous ris-
ing tide of interest in medical relationships, and
as clear an understanding that the obligations of
medicine are not entirely met just by a considera-
tion of the cure of disease after it has appeared.
It seems plain the the public expects from the pro-
fession a solution of these problems and that social
organizaUons, philanthropies, foundations and the
state itself, are simply aids and cooperative factors
and will remain so if the medical profession offers
leadership in the solution of these great problems
of health and sickness service. Just now we need,
as never before in the history of medicine, to ad-
vance our statesmanship. Just let me say in con-
clusion that changing times demand a changing
organization; that idealism is needed in medicine
today just as much as it ever was. Doctors do not
and cannot work without it. The majority of
doctors everywhere are as great idealists today as
they ever were. However, I have sometimes heard,
in discussions in this state, of medical commercial-
ism that seemed to make ideals gasp for breath.
We need in medicine, no less than in all public
life, a spirit that will not set private gain above
common welfare or the common good. And then,
when we are tired of everything else, we might
remember what Osier said, that “medicine is an
art not a trade, a calling, not a business, a calling
in which there is exercise for the heart as well
as for the head”.
Discussion
Dr. Overton : May I introduce a personal note,
which is possibly not entirely appropriate to what
Dr. Ross has said. Dr. Ross started by saying that
he had not prepared a paper and then he stated that
at Poughkeepsie last night he had written out a
speech. I want to tell you, gentlemen, that Dr.
Ross has made more than 100 speeches since he
became President last June. He has written out
510
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
every one of those speeches in his office and he has
gone to every meeting prepared to speak to that
particular meeting with an individual talk, and he
came here with an individual talk to us. Yrou will
remember that at the last meeting of this confer-
ence Dr. Ross was down for a discussion but he
came with a written speech. In other words, he
prepares himself and that is the secret of why he
is in demand all over the state to deliver speeches.
The preparation takes a much longer time than it
does to deliver a speech.
Dr. Ross has brought out the points of recom-
mendation made by the Governor’s Commission
which will probably be enacted into law. I want
you to notice as you read these recommendations
that there is no suggestion as to what the doctors
are to do. Dr. Ross says that the doctors them-
selves practice good scientific medicine, that there
is no scientific problem, that, in other words,
these laws are not directed against the doctors.
But, the laws specify what the municipalities shall
do in every instance; there shall be a county
health department and the establishment of county
hospitals in New York State. Last year we passed
the Welfare Law providing that there should be
a County Welfare Commissioner, and that has
solved some of the medical problems. It is not
what the doctors shall do for the practice of medi-
cine, it is what the public, particularly the munici-
palities, shall do. Now, we who have borne the
heat and burden of the medical profession for these
many years know that there is often no facility to
help us in our work. There are in some districts
no hospitals and it is difficult to work in the homes
of the poor. All this law is administrative and
deals with what the public shall do. In other
words, if the public would do half as much as the
doctors have done we would have less difficulty.
Dr. Ross spoke of the idealism of the doctors. I
don’t think he meant to imply that the doctors are
not already imbued with that. The most hard
boiled doctors in my own county are delighted with
this public welfare law and are glad to have the
County Commissioner instead of the overseers of
the poor, and that he shall provide medical atten-
tion for those otherwise unable to get it. A man
who has several children, who works and is a good
honest fellow, may be suddenly taken with pneu-
monia and his income cut off. Under the old sys-
tem the physician would get nothing for attending
that man. Under the new system, if he cannot
pay for medical attention the county will pay for
it under agreement with the county commissioner.
Now that is the biggest advance that we have had
in the economics of the practice of medicine.
Dr. Ross: I want to supplement all of this by
saying that every practice adopted under this law
is under the state aid. The thought came to me
while talking at the lit*le County of Greene meet-
ing the other night that it is perfectly delightful
to find that where 10 doctors are gathered to-
gether you find the same degree of intelligence as
you find among 100. They worked out a plan that
would double their health activities in that county
at the same price that they were now paying for
it, or $13,000 a year. They had worked out a sche-
dule that would double their activities at the same
cost and the state immediately gave them a check.
Greene County is next to the last county in New
Y'ork that has not a hospital within its boundaries.
They have gathered a fund of $35,000, the super-
visors have voted to have a county hospital and
are adding something to that amount, and the
state has agreed to match it. So that leaves only
1 county without a hospital.
This method of solving our problems by meeting
our obligations is bringing a remarkable response
from the whole country. In this small group, I
think I can tell you, and I hope you will not think
that there is the slightest degree of ego about it, my
personal correspondence this year numbered 1G21
letters that I have dictated, every one of them on
the problems of medicine, the obligations of service
and the relationships that medicine must assume,
all with the idea of solving the problems of medi-
cine, putting medicine in its place of leadership.
There must be a recognition that medicine and the
public are partners, that the profession must fur-
nish the leaders but that the people are the re-
cipients.
Dr. Morrison: I think New Y'ork State is to be
highly congratulated this year on the personality
of its President. He has done a job that probably
has never been so well done in the medical circles
of New Y'ork State before and he is setting a pace
for those who fill the chair in the future if they at-
tempt to follow in his footsteps. YVe are always
grateful to Dr. Ross when he brings his talks to
this conference in the spirit in which he has done
it today. The conception of this Tristate Confer-
ence was an attempt upon the part of the members
and the leaders of the medical profession to break
away from the old traditions of medicine and try
to teach the profession in these 3 states the re-
sponsibilities that it owes to the public. It was
that, I imagine, that Dr. Snedecor referred to
when he said there had been a renaissance in
medicine in New Jersey. The thought occurred to
us that we must realize that doctors have a larger
duty than to treat those who are critically ill and
sick. The public looks to us and is beginning to
demand leadership and advice in the health prob-
lems that are so rapidly coming to the front, and
it is our constant endeavor in New Jersey to carry
out the very policy that Dr. Ross has laid down, to
carry to the county society the idea that we must
broaden the scope of our activities and accept the
new responsibilities that the conditions of the
times are imposing upon us. The public is looking
to us and expecting leadership. The social and
labor groups, all those Foundations and Boards
that are interested in child health and the welfare
of the public, are looking to us for counsel and
leadership. YY'e shall look forward with a great
deal of pleasure to an analysis of Governor Roose-
velt’s report when it comes to our hands next May
for study. It will also give us many leads to fur-
ther the work that we have already been doing.
In New Jersey we have been particularly for-
tunate in recent years in the progress of our Pub-
lic Health Departments. We have a full-time
health officer in Jersey City, Newark, East Orange,
Paterson and Trenton and we have half-time offi-
cers in many smaller communities. We have tuber-
culosis hospitals, apart from the State Hospital, in
several counties, Mercer, Atlantic, Essex. The cure
of tuberculosis is going on at a fairly rapid rate
and the incidence of tuberculosis is decreasing with
enormous rapidity. We are very proud indeed of
our record.
I am very glad that the ideas of this Conference
in the last few years are leading us to promulgate
more activity with a full sense of responsibility
that the profession has toward the general health
of the public.
Dr. Patterson: I hesitate to discuss your very
excellent presentation of this very important sub-
ject. I find myself so entirely in agreement with
v hat you have said that what I shall say is only
a repetition of that already presented, and a less
well thought out presentation than that which you
have made.
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
511
Looking over the whole field of medicine it does
seem to me that the advance of medical knowledge
is reasonably satisfactory as carried on in our re-
search institutes and by research workers. Prog-
ress is being made all the time, very gratifying
progress, and medical education is reasonably
satisfactory and has made wonderful progress in
the past 25 years without question. It is true
that those teaching institutions which did not
come up to satisfactory standards have been elimi-
nated and that those that are left are all meritor-
ious, and it is a matter of particular gratification
to know that. The future doctors of the nation,
as determined by the young men being admitted
to the medical schools of today, will be better than
ever before. I suppose medical teaching falls
somewhat short of utilizing all medical knowledge.
It seems to me that medical practice probably falls
considerably short of utilizing all that is taught
in the medical schools and is therefore 2 jumps
behind the best of our medical knowledge. It does
seem to me that so far as the practice of medi-
cine is concerned, as regards the relation of the
doctor to his individual patients, conditions of
practice were never more satisfactory than they
are at the present time, and that is no longer a
real problem. I quite agree with you that the real
problem before the medical profession today is
meeting the conditions of community health, and
there are a large number of them, and in that en-
deavor we fail to a far greater degree than we did
in any of our other endeavors. Now, is it not
true that industry is more alert in utilizing medi-
cal knowledge for solution of its problems than the
profession is in handling public health prob-
lems? Is not that a source of one of our fears of
what might be called the industrialization of medi-
cine? If the medical profession itself were as
alert and as efficient in utilizing medical knowl-
edge for the solution of these problems to which
you point, venereal disease control, cancer and
tuberculosis control, and the care of the indigent
sick, those problems would not be so great as they
are now. And, of course, it is true that if we do
not take the lead in directing these activities,
leaders of industry, or political leaders, or others,
will take it from us and our position will be rela-
tively less satisfactory and the profession will lose
in prestige.
I feel that Dr. Ross should be commended for
the most admirable work which he has done. If
we had many such leaders as Dr. Ross in the medi-
cal profession the solution of our problems would
advance apace. My remarks have really added
nothing to this discussion but I did not want the
opportunity to go by without giving Dr. Ross a
special word of encouragement.
Dr. Ross: All of this is very helpful. I just want
to tell you one interesting little thing. Recently I
attended a meeting in Utica, by invitation, and I
found the county society had sponsored the move-
ment and there were present 120 delegates from 60
social organizations. I had the impression there
of the power of public opinion. Those 60 organ-
izations represented health and welfare. They rep-
resented the Parent-Teacher Associations and
every organization on earth I had ever heard of,
even a Bureau of Home Economics of Cornell
University. I was never before so impressed with
the fact that health questions are becoming public
matters, and constructively so. I just recall some-
thing that the editor of the London Lancet said
not long ago: “No longer is the medical man the
sole repository of medical knowledge but he must
take his place in the ranks of other scientific
workers.’’ I received just that impression.
The meeting formally adjourned at 3 p. m.
Henry O. Reik, M.D.,
Secretary.
THE NEW JERSEY CONFERENCE ON CHILD
HEALTH AND PROTECTION
Reported by Dr. Ellen C. Potter
The physicians of New Jersey have a very
special interest in the outcome of the New Jersey
Conference on Child Health and Protection, since
on their cooperation and leadership the success of
the future program depends, not only in the field
of health but in that of social welfare. To an un-
usual degree the medical profession was called
upon to formulate the program and they partici-
pated in the discussions during the sessions held on
April 17 and 18 at the New Jersey College for
Women at New Brunswick.
As the White House Conference, called by Presi-
dent Hoover in November 1930, studied the present
status of health and well-being of the children of
the United States and its possessions, and re-
ported on what is being done for them and
should be done; so, the people of New Jersey
called by Governor Morgan F. Larson found it
wise to get together in conference to sum up the
entire situation of child health and welfare in this
state, to measure the state’s facilities and program
with the standards set by the White House Con-
ference, and to make recommendations bearing on
the immediate needs and looking toward future
accomplishments.
The recommendations of the White House Con-
ference, based on a 16 months’ study by 1200 ex-
perts in problems of childhood, from all sections
of the United States, can be carried out only as
their importance is realized and they are brought
to completion by public or private agencies in the
states and local communities, and, for this reason,
the citizens of New Jersey came together to study
their problem.
Registration
The conference was conducted at the Governor’s
request by the New Jersey Conference of Social
Work, of which William J. Ellis is President, in co-
operation with the 4 major state departments that
deal with the child: the Department of Education,
Department of Health, Department of Institutions
and Agencies, and the Department of Labor.
Altogether 1700 persons met, representing these
state departments; county, municipal and private
agencies which are in close contact with children ;
members of public and private social welfare
agencies interested in the development of whole-
some family and community life; and other
socially minded citizens from all parts of the state.
Delegates were present from the Parent-Teachers’
Association, the State Federation of Women’s
Clubs, League of Women Voters, State Nurses’
Association and the Public Health Nurse Associa-
tion, State Medical Society, Freeholders’ Associa-
tion, Probation Officers’ Association, State Police,
fraternal, service, recreational and character-
building organizations, Protestant, Catholic and
Jewish societies, the American Legion, Urban
League, and students from the state universities.
512
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
The Program
The conference was divided into 4 general sec-
tions which in turn were subdivided into smaller
groups for the general discussions growing out of
specific subjects presented. Dr. Ellen C. Potter
was chairman of the general program.
The Medical Service Section had as its chairman
Dr. Allen G. Ireland, Director of Physical and
Health Education of the New Jersey State De-
partment of Public Instruction. During this ses-
sion Dr. Edgar A. Doll, of the Vineland Training
School, spoke on “Growth and Development”. Fol-
lowing him there was a talk on “Prenatal and Ma-
ternal Care” by Dr. S. A. Cosgrove, of the Mar-
garet Hague Maternity Hospital, in Jersey City.
Then there was a discussion of “Medical Care for
Children”, by Dr. Julius Levy, consultant for the
Bureau of Child Hygiene in the New Jersey State
Department of Health. A general discussion of
these topics followed their presentation.
The Public Health and Administration section’s
chairman was Dr. Stanley H. Nichols, who is
chairman of the Public Health Committee of the
Monmouth County Medical Society. Public Health
Organization, Communicable Disease Control, and
Milk Production and Control were the general sub-
jects which were presented in their several phases
by able speakers and experienced administrators.
The Education and Training Section, under the
chairmanship of Dr. Bruce B. Robinson, was di-
vided into 8 groups for the discussion of special
topics, as follows:
(1) Parental Education, Mrs. William F. Little,
Chairman.
(2) Vocational Guidance, Herbert Meyer, Chair-
man.
(3) Child Labor, Mrs. Isabelle M. Summers,
Chairman.
(4) Recreation, Lewis R. Barrett, Chairman.
(5) Special Classes, Meta Anderson, Chairman.
16) Mental Hygiene, James S. Plant, Chairman.
(7) Spiritual Training, Ralph Glover, Ph.D„
Chairman.
(8) Library Extension and Children’s Reading,
Edith Smith, Chairman.
The Handicapped Section, under the chairman-
ship of Edward R. Johnstone, met in 5 groups.
The first considered the “Physically Handicapped”
(the blind and partially seeing, the deaf and hard
of hearing, the crippled, the children with internal
conditions such as tuberculosis and heart diseases),
ways of preventing such physical handicaps and
the vocational adjustment of the handicapped.
Joseph G. Buch, Chairman of the New Jersey Crip-
pled Children’s Commission, was chairman of this
group.
The Mentally Handicapped under the group
chairman. Dr. Joseph E. Raycroft, Chairman of
the Board of Managers of the Trenton State Hos-
pital, were considered from the angles of the
clinics, psychiatric, social service and institutional
care for the mentally disturbed, the feeble-minded
and the epileptic.
Mrs. Thomas W. Streeter presided over the De-
pendency and Neglect group which considered the
prevention of dependency, the administration of
relief, and other phases of child dependency.
Delinquency and its problems was presented
through consideration of the juvenile courts, pro-
bation, detention, and improvements needed in
handling the delinquent children, under the chair-
manship of Dr. James S. Plant, Director of the
Essex County Juvenile Clinic.
Community Organization for the Handicapped.
with emphasis on the value of county- wide ser-
vices, was presided over by Mrs. Harriman N.
Simmons. President of the Council of Social Agen-
cies, of Elizabeth.
In the 2 days, 103 speakers, each a specialist
on some phase of child health or welfare, were
heard at some of the 25 sectional and general meet-
ings on April 17, and the 12 on April 18.
The program mapped out for developing the
child and preparing him for his living and for his
life’s work, included: thorough examination of all
children to discover and diagnose early any ab-
normalities that need curative or remedial treat-
ment: treatment to adjust any handicaps; educa-
tion, both academic and vocational, to the fullest
possible extent of his abilities; recreational facili-
ties in a community alive to its responsibilities;
protective legislation: and research into all fields
of child welfare to prevent and control anything
detrimental to childhood; development of district
and municipal public health organization and full-
time trained service; and comprehensive recre-
ational programs.
Resolutions were formulated by the committees
after discussions; presented to a resolutions com-
mittee of the conference as a whole; and consider-
ed and adopted by the entire conference at the
closing meeting.
Summary of the Resolutions
The resolutions adopted by the conference took
cognizance of the ways in which our present
facilities, organizations, and legislation fall short
of the needs of the normal child, as well as the
dependent or neglected child and the physically
or mentally handicapped. They include certain
standards for which the state should strive and
they specifically ask for definite action on the
part of governmental bodies for the health, edu-
cation and protection of the children, for legisla-
tion whenever it is necessary to bring the desired
results, for complete surveys where only general
facts or conditions make impossible a real picture
of the problem.
A Continuation Committee on Child Health and
Protection, as a committee of the New Jersey
Conference of Social Work, was constituted by the
conference to carry into effect the recommenda-
tions that the childhood and youth of New Jersey
might receive the maximum benefits. A number of
physicians are members of this Continuation Com-
mittee.
The specific recommendations that require re-
sponse from a definite group include that the State
Board of Education shall :
(1) Appoint an advisory council to study ways
of making specialized education available to local
districts and to give adequate opportunities to the
gifted child.
(2) Establish classes in parent education for
intelligent and inquiring parents.
(3) Set up minimum standards as to the num-
ber, qualifications and training of school atten-
dance officers: (a) Governor be requested to ap-
point a committee to study the efficiency of local
health administration in small districts for the
purpose of suggesting legislation, (b) Health offi-
cers be full-time workers, (c) The various state
and local departments engaged in the work of
child care and protection be reviewed for further
advancement of their activities. fd) Additional
legislation be enacted for the protection of chil-
dren in industry and for the migratory child, (e)
Civil Service Commission keep its standards high
for all social workers who deal with children, (f)
A research council be formed to promote co-
operation in child research.
General recommendations suggest that: (a) ade-
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
513
quate public or private child caring agencies be
established in the state for the protection and care
of children, thus providing case work facilities to
prevent delinquency and dependency and subse-
quent commitment of children to the care of the
state; (b) desertion and nonsupport laws be more
strictly enforced; (c) money earned by prisoners
be applied to the relief of their families and that
employment of prisoners be increased when feas-
ible; (d) the state and local systems of mental and
tuberculosis clinics be further enlarged, and psyco-
pathic wards in general hospitals be further de-
veloped: (e) the principles of mental hygiene be
taught in the colleges, medical, law, and divinity
schools, police training schools and the like; (f)
health education be emphasized in the secondary
schools and colleges that adults may be prepared
to guard child health; (g) facilities for treating
contagious diseases be increased; (h) funds be made
available for developing a research program into
the causes, prevention, treatment and education of
the physically handicapped child; (i) state co-
operate with the county administration of proba-
tion and a state-wide program for the extension
of probation be developed.
Recommendations were also made that there be
set up in the Department of Education a central
bureau of pupil Dersonnel guidance; that school
boards and municipalities provide adequate play
space and facilities for all age groups; that public
libraries, municipal and county, and school
libraries be adequately supported and promoted
and that the use of libraries by children be en-
couraged.
Childrbn-’s Bill of Rights
A “bill of rights” was adopted enumerating the
rights to which all the children of the state are
entitled whether they live in the city or in the
country, in the remote sections or in the centers
of population, whether they be rich or poor, physi-
cally and mentally able or handicapped.
The conference agreed that all children of New
Jersey had:
A Right to Happiness, as represented by the
spiritual and moral training and sympathetic at-
mosphere of a home financially secure in a com-
munity affording adequate recreational facilities.
A Right to Health, as represented by prenatal
and postnatal care, nourishing food, sanitary liv-
ing conditions in school, home and community and
health education and protection.
A Right to Growth, physical, mental educa-
tional, personal, and recreational from an un-
hampered childhood throughout youth to adult
life.
Results
The uniting of all the forces in the state work-
ing for the betterment of conditions relating to
children is perhaps the most important outgrowth
of the conference. Through this renewed co-
operation, the child himself will be considered by
the groups in the future, and programs will not
emphasize one phase of his development as separ-
ate from the others.
The practical results will be manifest during the
next few years as the recommendations of the
conference are carried out through the cooperative
effort of existing state and local organizations.
The Continuation Committee will further the
program of child health and protection and will
give publicity to the needs of all children so that
there may be developed the will on the part of the
people of the state to provide for their needs in
the unshakable faith that the childhood of the
state~ is its most precious possession, an asset in
whose interest every sacrifice is supremely worth
while.
AMERICAN COLLEGE OF PHYSICIANS
(Proceedings reported by Dr. W. Blair Stewart,
of Atlantic City.)
The Fifteenth Annual Session of the American
College of Physicians was held in Baltimore, Mary-
land, March 23-27. General Headquarters, Ses-
sions and Exhibits were located in The Alcazar.
Dr. Maurice C. Pincoffs, Baltimore, was Chairman
of Committee of Arrangements, ably assisted by
Dr. Sydney R. Miller, President of the College, and
an efficient corps of assistants. Clinics and demon-
strations were given every afternoon in the various
hospitals of Baltimore. Every subject of Internal
Medicine was ably covered. The general sessions
were held morning and evening and were devoted
to a most instructive series of symposiums on
Gastro-Intestinal Disease, Heart Disease, Public
Health, Medical Practice, Medical Economics, En-
docrine Disorders, Anemia, and general subjects.
The latest research work on all these branches
was presented in such an interesting and instruc-
tive form that the whole meeting was converted
into one of the best post-graduate courses on In-
ternal Medicine ever staged. It will be impossible
to review even the high spots in this report. All
papers will be published in the coming monthly
issues of Annals of Internal Medicine, the Official
Journal of The American College of Physicians.
Without doubt the outstanding address was the
classic talk by the Dean of American Medicine,
Dr. William H. Welch, who spoke on “research
and historic medicine”.
The various reports show a healthy growth of
the College in science and research, as w^ell as
an increment of a large number of America’s best
internists. There are 8 Masters of the College;
2297 active Fellows and 583 Associates — a total
membership of 2888. Of this number, 366 were
elected at this session. The Treasurer’s report
showed a net balance of $23,214 for 1930 which,
added to the Endovunents and general fund,
amounted to $88,338 — a very healthy financial con-
dition for such a young organization. The official
Annals was published witll a surplus of $561 at
the close of its year, March 1931.
Aside from routine business at the annual
meeting, the following resolution -was enthusias-
tically adopted, only 1 vote being cast in the
negative.
Text of Resolution
“The enactment of laws by the United States
Congress and many State Legislatures has de-
prived the medical profession of its inherent and
deputized rights to prescribe drugs and remedial
measures in such quantity as it may deem neces-
sary in treating the sick.
New laws and regulations have been and are
now being forced upon medical men to such an
extent that they can no longer be the judge of
their own methods or treatment, but must bow to
the prescribed form of non-professional legislators
and boards.
State medicine is gradually undermining the
ancient and traditional rights of medical practice
and, if continued at its present rate, legitimate
practice will soon be displaced by a commercial
type of cults and advertised self-methods of treat-
ment by patent and proprietary medicines.
514
JOURNAL OF THE MEDICAL SOCIETY O-F NFAV JERSEY
June, 1931
Recognizing these deplorable conditions, the
American College of Physicians, met in regular as-
sembly, recommends:
(1) That every legitimate effort be made to im-
press upon the members of Congress that un-
restricted medical treatment of disease by properly
licensed physicians should be granted, and that
they should not be penalized on account of the
misuse of medical methods by a very small per-
centage of so-called medical and non-medical men.
Let the profession be its own judge of how it can
best treat the sick, and properly penalize those
who flagrantly abuse their licensed or unlicensed
trust.
(2) That the fellows and associates of the col-
lege must become more active in medical legis-
lation and join with their state societies in an
effort to repeal inimicable state laws now en-
forced, and influence a higher type of medical
methods for the further protection of the sick
and those to whom their lives are entrusted.”
Dr. S. Marx White, Minneapolis, Professor of
Medicine in the University of Minnesota, was
elected President for the ensuing year. Dr. Francis
M. Pottenger, Monrovia, California, a specialist in
diseases of the chest, was made President-Elect.
Dr. Aldred Scott Warthin, Ann Arbor, Michigan,
First Vice-President. Dr. Charles G. Jennings,
Detroit, Second Vice-President. Dr. John A.
Lichty, Clifton Springs, N. Y., Third Vice-Presi-
, dent. Regents and Governors were also elected.
The total registration for the session was over
1800. The next meeting of the College will be held
in San Francisco in 1932 — date to be decided later
by the Regents. There were over 60 commercial
exhibitors of A. M. A. standard type. New Jersey
was represented by 85 Fellows and Associates.
A post-convention session of clinics was held
in Washington, D. C., on Saturday, March 28.
Opportunity was also given to visit the various
Government museums, libraries and public build-
ings.
Among those attending sessions of the Congress
were the following doctors from New Jersey:
John Wesley Gray, Edward C. Klein, Jr., and
Charles L. Rosenberg, of Newark; Harry Bloch,
Arturo R. Casilli, Horace R. Livengood and Michael
Vinciguerra, of Elizabeth; John V. Smith, of
Perth Amboy; William W. Davies, of Lakehurst;
Clyde M. Fish, of Pleasantville; Philip Marvel, Sr.,
Philip Marvel, Jr., W. Blair Stewart, William w!
Fox and Samuel L. Salasin, of Atlantic City;
William G. Herrman, of Asbury Park; Frank C.
Johnson, of New Brunswick; Richard E. Knapp,
of Hackensack; Marcus. W. Newcomb, of Brown’s
Mills; William S. Collier, Barney D. Lavine, Na-
than Swern and Harry D. Williams, of Trenton.
The list of newly elected Fellows of the Ameri-
can College of Physicians includes the following
New Jersey physicians: Harry Bloch, Elizabeth;
Arturo Raymond Casilli, Elizabeth: William
Shreve Collier, Trenton ; William Walter Davies,
Lakehurst; Clyde Mulhollon Fish, Pleasantville;
William Wellington Fox, Atlantic City; John Wes-
ley Gray, Newark; William Gettier Herrman,
Asbury Park; Frank Chambliss Johnson, New
Brunswick and Plainfield; Edward Caffron Klein,
Jr., Newark; Richard Edward Knapp, Hacken-
sack; Barney Doibe Lavine, Trenton; Horace
Rutherford Livengood, Elizabeth; Marcus Ward
Newcomb, Brown’s Mills; Louis Charles Rosen-
berg. Newark; Samuel Lyon Salasin, Atlantic
City; John Vincent Smith, Perth Amboy; Nathan
Swern, Trenton; Michael Vinciguerra, Elizabeth;
Harry David Williams, Trenton.
Public Relations
THE CONTROL OF PROPRIETARY
MEDICINE
(From the London letter, Jour. A. M. A.,
Mar. 7, 1931.)
A bill emanating from the health advisory
committee of the Socialist party, to be known as
the proprietary medicines bill and intended to
regulate the manufacture and sale of such prep-
arations, is about to be brought forward. Its
provisions are drastic, and considerable opposi-
tion is already announced by manufacturers and
pharmacists, but the provisions should with one
exception receive approval from the medical pro-
fession. It is proposed to appoint a registrar
to keep a book containing the names of the
owners of all proprietary medicines and full par-
ticulars of their ingredients. Every such medicine
must be registered and allotted a number, which
must figure on any vessel or packet in which it is
sold. The advertising of proprietary medicines
is to be rigorously censored. No statement that
a physician or dentist has recommended such a
preparation may be published without his qual-
ifications and address. It may be remarked that
this practice is forbidden by the ethical rules of
the medical profession. Quotations from medi-
cal journals must be accompanied by the name,
date and page of the publication. It will be an
offense for the vender of a proprietary prepara-
tion to invite persons suffering from any ailment
to correspond with him with a view to treatment.
After 6 months from the passing of the act, no
person will be permitted to sell any medicines
or appliances purporting to cure or relieve deaf-
ness, or any other of 10 ailments mentioned in the
bill. The Minister of Health will be empowered
to remove from the register any medicine that he
considers likely to cause injury if used in accord-
ance with its registered directions. One of the
chief objects of the bill is the establishment of
a new government department to act as an offi-
cial censor of advertisements. The trade interests
concerned will do everything in their power to
oppose the bill, as they maintain that the compul-
sory publication of formulas would have the
gravest effects on well known proprietary busi-
ness.
A “WHITE-COLLAR” HOSPITAL THAT IS
PROVING THE CASE
(From Newark Evening News, Mar. 9, 1931.)
There has been much talk and some planning
toward hospitals for the less than well-to-do and
the not-yet-poor in New York and elsewhere in
this region. In Boston such a hospital has been
in operation a year. The results it has attained
are instructive. They justify the belief of some
medical men and many others that the problem
of the high cost of being sick is not beyond solv-
ing.
The hospital is the Baker Memorial, a unit of
the Massachusetts General. For a century the
latter institution has been primarily for the poor,
receiving from its patients only what some of
them felt they could contribute toward the cost
of what the hospital gave them. In 1917 Phillips
House was built and equipped to provide private
rooms and the type of service required by those
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
515
who do not have to consider cost. There remain-
ed unconsidered in the Massachusetts General, as
in most hospitals, the great middle class whose
means are limited, but whose economic status
and self-esteem make them both ineligible for
and unwilling to accept charity, even in time of
grave illness.
Baker Memorial was constructed to meet this
need, $1,900,000 being provided for the purpose.
The first patient was received March 3, 1930, To
December 31 it served 1973 patients, whose av-
erage income, or the average income of the bread-
winners in their families, was $2101. The average
time of their stay in the hospital was 13 days, and
the average cost per patient $158.94. Of this total,
hospital charges consumed $94.48, doctor’s fees
$55.71. Total expenses of the institution amount-
ed to $282,539.19 and total receipts were $213,-
884.08, leaving a deficit for the 10 months of $68,-
655.11.
This deficit is smaller than was expected. It has
been underwritten for 3 years by the Julius
Rosenwald Fund to encourage t-he experiment,
and is expected to decline this year to $35,000.
That it may be overcome when the full capacity
of 3 30 beds, of which only 150 are now in use,
become available is apparently within the possi-
bilities. Medical and surgical fees are limited
to $150 a patient, no matter what type of service
is rendered or over what period. Beds with nurs-
ing attendance and ordinary medication range
from $4 in a 9-bed ward to $6.50 in single rooms.
The anesthetic fee is $5, the operating room
charge $15, with proportionate charges for x-ray
and other special services.
School Health Department
MINIMUM BIBLIOGRAPHY FOR SCHOOL PHYSICIANS
Allen G. Ireland, M.D.,
Director of Physical and Health Education, State Department of Public Instruction, Trenton
Andress
Health Education in Rural Schools
Houghton Mifflin
1925
Averill
Educational Hygiene
Houghton Mifflin
New York
1926
$2.00
Averill
The Hygiene of Instruction
Houghton Mifflin
1928
2.00
Ayers, Williams, Wood
Healthful Schools, How to Build,
Houghton Mifflin
1918
2.25
Equip and Maintain Them
Bennett
School Posture and Seating
Ginn and Co.
1928
■Cornell
Health and Medical Inspection of
Davis
1922
School Children
Dickson & Dineley
Examination for Health and Cor-
Lippincott
2.00
rection
Fisk and Crawford
How to Make the Periodic Health
Macmillan
1928
4.00
Examination
Keene
The Physical Welfare of the
Houghton Mifflin
School Child
New York
1929
Morrison and Chenowith
Normal and Elementary Physical
Lea & Febiger
Diagnosis
Philadelphia
1928
Newmayer
Medical and Sanitary Inspection
Lea & Febiger
1913
4.00
of Schools
Roberts
Nutrition Work with Children
Univ. of Chicago
Press — Chicago
1927
3.50
Wood and Rowell
Health Supervision and Medical
Saunders
Inspection of Schools
Philadelphia
1927
7.50
Wood and Rowell
Health Through Prevention and
World Book Co.
1925
Control of Disease
Monthly Bulletin of American Association of School Physicians —
Dr. William A.
Howe, State Department of Education,
Albany, New York.
Publications of the American Child Health Association, 450 Seventh Avenue, New York City,
New York.
Physical Measures of Growth and Nutrition, Franzen It 1929
Present Practices in the Light of Recent Research, Whitney A., and Palmer, G. T. 1930
Public Health Aspects of Dental Decay in Children, Franzen, R 1930
School Health Progress — Sayville, L. I., Conference Report 1929
Publication of National Society for the Prevention of Blindness, 450 Seventh Avenue, New York
City, N. Y.
Conserving the Sight of School Children — Wood, T. D. and Committee 1928
(Bibliography supplied upon request)
Publication of Joint Committee of National Education Association, and Amercian Medical Association
Health Education — National Education Association — Washington, D. C. 1930
DIG
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
State Health Department
NARCOTIC CONTROL
D. C. Bowen, Director of Health
New Jersey State Department of Health,
Trenton, N. J.
Those interested in statutory control of habit
forming narcotic drugs and treatment of addicts
are vitally concerned with the proposal of the
United States Public Health Service, in April, for
further state regulation of narcotics.
The New Jersey Legislature in 1929 enacted
Chapter 301 as its latest pronouncement governing
prescription and sale of narcotics by recognized
authorities subject to state control.
The proposal of the United States Public Health
Service made orally April 17 for state assistance in
enforcement of the Harrison antinarcotic statute
was not a complete surprise to officials of New
Jersey. In substance, the plan of the U. S. Public
Health Service is modeled similarly to the legal
machinery for enforcement of the eighteenth
amendment of the United States constitution, i.e.
the federal enforcement act synchronizing with
the several state enforcement laws on the same
subject.
The New Jersey antinarcotic law. Chapter 301
of the Laws of 1929, in general, specifies those who
may manufacture, prescribe, sell and distribute
drugs in the interest of the conservation of human
life in emergencies. Records pertaining to ad-
ministration of the statute in question, filed by
medical practitioners, are confidential, in the
archives of the State Department of Health, ex-
cept for the purpose of enforcing the law, under
penalty of a fine not exceeding $1000, imprison-
ment of 1 year or both.
The proposal of the U. S. Public Health Service
for control of habit forming narcotic drugs and
the treatment of addicts embraces those features
which are said to be exclusively within the do-
main of state enactment.
These include laws controlling the sale and use
of chloral hydrate, cannabis and peyote, as well
as the exemption of preparations containing such
drugs or their possession, the sale and possession
of hypodermic syringes; the prescribing of nar-
cotic drugs for habitual users thereof; the revo-
cation of professional licenses to practice; the
further curtailment of exempt preparations; the
commitment of drug addicts to institutions for
treatment; the declaring of buildings or resorts
where narcotic drugs are illegally sold or used to
constitute public nuisance and the instruction in
public schools as to the effect of narcotic drugs
Further the proposal of the United States Pub-
lic Health Service was outlined as follows:
“So far as the requirements of the Federal law
are concerned, they take precedence over state
laws and must be complied with, as a minimum,
by all persons who are engaged in the sale or use
of restricted- narcotic drugs. On the other hand,
in those instances where State laws are more com-
prehensive than the Federal law, those more com-
prehensive requirements are not set aside by the
Federal law, but serve to emphasize the need for
additional restrictions as to the sale of habit-
forming narcotic drugs.”
The State Department of Health is calling atten-
tion to the suggestion of the United States Public
Health Service at this time in order that there may
be adequate consideration of the entire subject by
interested parties.
Communications
REPORT OF PROSECUTIONS FOR ILLEGAL
PRACTICE
(Submitted by Dr. James J. McGuire, Secretary of
the State Board of Medical Examiners.)
December 5, 1930, Walter B. Carr, of Millville,
a naturopath, was found guilty of practicing
medicine without a license.
December 11, 1930. James W. Frazer, a licensed
chiropractor, of Bayonne, pleaded guilty in the
First District Court of Jersey City to a charge of
practicing medicine without a license. The charge
against Frazer was based upon the fact that he
exceeded his license to practice chiropractic by
giving drugs.
December 11, 1930, Roger Henry, Jr., of Trenton,
pleaded guilty in the Trenton District Court to a
charge of practicing medicine without a license.
December 15, 1930, Dabbi Francisco, who con-
ducted the Little Spanish Homeopathic Drug Store
at 153 S. Orange Avenue, Newark, was found
guilty of practicing medicine without a license
by the Judge of the Second District Court of
Newark.
January 15, 1931, Helen Quasdorf, of Clifton,
who advertised electric treatments, colonic irriga-
tions, etc., paid the penalty for practicing medi-
cine without a license.
January 21, 1931, Eugene B. Taylor, of Cran-
ford, was found guilty of practicing medicine with-
out a license by the Judge of the Elizabeth Dis-
trict Court.
January 27, 1931, Frank Vermeulen, a chiro-
practor, of Paterson, was found guilty of practic-
ing medicine without a license by the Judge of
the Paterson District Court.
February 11, 1931, Joseph C. Kindler, a physio-
therapist, of Jersey City, pleaded guilty in the
First District Court of Jersey City to a charge of
practicing medicine without a license.
February 19, 1931, Hugh F. Mitchell, of West
New York, who held himself out as a medical
doctor, was found guilty of practicing medicine
without a license by the Judge of the First Dis-
trict Court of Jersey City.
March 4, 1931, Mary Kaczmarek, a licensed
midwife, of Perth Amboy, was found guilty by
the Judge of the Perth Amboy District Court, of
practicing medicine without a license. She ex-
ceeded her license by administering pituitrin to
patients.
March 4. 1931, Joseph Brander, of South Amboy,
pleaded guilty to a charge of practicing medicine
without a license in the Perth Amboy District
Court.
On the same day Miriam Resnick, a masseuse, of
Perth Amboy, paid the penalty for practicing
medicine without a license.
March 11, 1931, Hildur Karlson, who conducts
the Karlson Baths on the Boardwalk in Atlantic
City, paid the penalty for practicing medicine
without a license.
June. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
517
On the same clay, Kathryn McBride, of Atlan-
tic City, who was giving electric treatments, paid
the penalty for practicing medicine without a
license.
March 11, 1931. Don D. Modica, of Atlantic City,
was found guilty on a second charge of practicing
medicine without a license by the Judge of the
Atlantic City District Court.
March 30, 1931, Evelyn AYienckiewicz, of Irving-
ton, a naturopath, pleaded guilty in the Second
District Court of Newark, to a charge of practic-
ing medicine without a license.
April 4, 1931, Theodore B. Mickley, a masseur of
Perth Amboy, paid the penalty for practicing medi-
cine without a license.
April 9, 1931, Paolo Piccone, of Hackensack, was
convicted in the Englewood District Court on a
charge of practicing medicine without a license.
Piccone was giving drugs to his patients.
April 10, 1931, Alfonso De Mercurio, a druggist,
of Bayonne, paid the penalty for practicing medi-
cine without a license.
April 14, 1931, William C. Roller, an unlicensed
chiropractor, of Bayonne, was found guilty in the
First District Court of Jersey City, of practicing
medicine without a license.
April 21, 1931, David Decker, of Newark, who
prescribed Indian Herb Remedies for his patients
and who had been found guilty of practicing medi-
cine without a license by the Judge of the First
District Court of Newark, was committed to jail
for 30 days.
April 24, 1931, Walter C. Quinn, an electro-
therapist, of Plainfield, pleaded guilty to a charge of
practicing medicine without a license in the Eliza-
beth District Court.
January 15, 1931, the Board revoked the license
to practice midwifery of Maria Vidale, who had
been convicted of practicing criminal abortion.
April 16, 1931, the Board revoked the license to
practice midwifery of Sophia Kovacs, who had
been convicted of practicing criminal abortion.
THE AMERICAN COLLEGE OF PHYSICIANS
San Francisco, 1932
The American College of Physicians will hold
its Sixteenth Annual Clinical Session at San Fran-
cisco with headquarters at the Palace Hotel, April
4-8, 1932. Following the Clinical Session, a large
percentage of the attendants will proceed to Dos
Angeles where a program, principally of enter-
tainment, will be furnished April 9, 10 and 11.
Announcement of the dates is made now with
a view not only of apprising physicians generally
of the meeting, but also to prevent conflicting
dates with other societies that are now arrang-
ing their 1932 meetings.
Dr. S. Marx White, of Minneapolis, is President
of the American College of Physicians, and will
arrange the Program of General Sessions. Dr.
William J. Kerr, Professor of Medicine at the
University of California Medical iSchool, San
Francisco, is General Chairman of Local Arrange-
ments, and will be in charge of the Program of
Clinics. Dr. Francis M. Pottenger, of Monrovia,
is President-Elect of the College, and will be in
charge of arrangements at Los Angeles. Mr. E.
R. Loveland, Executive Secretary, 133-135 S. 36th
Street, Philadelphia, Pa., is in charge of general
and business arrangements, and may be address-
ed concerning any feature of the forthcoming ses-
sion.
Woman’s Auxiliary
WOMAN’S AUXILIARY AMERICAN MEDICAL
ASSOCIATION
Ninth Annual Convention
Philadelphia, June 8-12, 1931
General Chairman,
Mrs. Walter Jackson Freeman
A message from Mrs. George N. J. Sommer,
Chairman of the Inter-County Committee.
Each County Chairman is advised to get as
much publicity as possible in the local newspapers
about the coming Convention. A photograph of
herself or of some other member who is active
in the County Auxiliary will not only awaken in-
terest in the Convention but will also create inter-
est in the work of the Auxiliary. Mrs. Freeman,
our General Chairman, hopes one of the results'
of the Convention will be an increased member-
ship in the County Auxiliaries.
Here is one announcement that must be given
circulation — All members of the Woman’s Aux-
iliary to the American Medical Association desir-
ing hotel reservations, and who are coming un-
accompanied, kindly send request to —
Mrs. Frederick S. Baldi, Chairman,
Hotel Committee, Woman’s Auxiliar5r,
Room 304, Chamber of Commerce Bldg.,
1129 Walnut Street,
Philadelphia, Pa.
On Monday, June 8, at 4.15 p. m. there will be
another general meeting of all the committees at
the Bellevue-Stratford. Mrs. Freeman will preside.
Please read the above announcements carefully,
note the dates and take action on the publicity.
W omen at the A. M. A. Meeting
A message from Mrs. Walter Jackson Freeman
The Woman’s Auxiliary to the American Medical
Association has been placed in charge of all en-
tertainment of women visitors, and began its
labors in June 1930 by engaging the whole Roof
Garden of the Bellevue-Stratford Hotel for the
period of the convention. All - women’s activities
will center in this hotel — registration, meetings,
luncheons and supper dance, and all excursions
will start from the Broad Street entrance. Invita-
tions and tickets must all be procured in the Roof
Garden in advance, as nothing but programs will
be obtainable elsewhere. Members of the A. M. A.
are invited to join all excursions, and should reg-
ister for them in advance in the Roof Garden.
Rooms for State Headquarters have also been re-
served in the hotel, and sponsors will be appointed
to look after all women registered from their own
states. The list of sponsors will be printed in the
program. The chairman of the Women’s Hotel
Committee is Mrs. Frederick S. Baldi, 2117 Porter
Street, Philadelphia, who will be glad to make any
desired reservations.
The convention will open with a subscription
buffet luncheon in honor of all National Auxiliary
Presidents from Mrs. Red to Mrs. McGlothlan, im-
5X8
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
mediately followed by 3 round tables of 35 minutes
each, with 10 minute intermissions, each under ex-
pert leaderships. The subjects will be:
(1) Programs for County Auxiliary Meetings.
(2) The Technic and Value of a Committee on
Public Relations.
(3) History and Archives.
These informal gatherings will be a sort of pre-
liminary canter, designed to bring together those
interested in special phases of auxiliary work and
give them opportunity to discuss the subject
thoroughly during the following days. The Na-
tional Board dinner and pre-convention meeting
are scheduled for Monday evening.
A new and, we hope, helpful feature will be a
Question and Suggestion Box to which we beg all
with good ideas to contribute. This seems the
most practical way of finding out what our mem-
bers want continued, what discarded, and what
plans are indicated for the future.
The regular business sessions will be held on
Tuesday and Wednesday mornings. National
Chairmen will be allowed 10 minutes for their re-
ports, State Presidents 3 minutes. Reports to be
printed may be as long as desired (in reason), but
let no one reporting on the floor imagine these
limits an idle jest. Nor will the hours announced
on the program be found to mean “about”. Have
your watches cleaned and regulated, and practice
your wrist drill before leaving home. You will need
it.
Thursday morning, too, will be a busy one, the
post-convention Board Meeting, a special meeting
for state and county treasurers desiring further
elucidation of the treasurers’ receipt blanks, and
at 10.30 an informal round table presided over by
the new president, the subject, “What Have I
Gotten Out of the Convention?” At this meeting,
Mrs. McGlothlan will announce her committee
chairmen and outline her plans for the coming
year, and the subjects in the Question Box will
be discussed; a sort of stock taking, closing the
year’s business, and opening the new books.
Philadelphia as an historic and cultural center
is the keynote of the entertainment planned for
our guests. Except Monday, all afternoons and
evenings will be devoted to pleasure, and a variety
of excursions is offered to suit all tastes, all physi-
ques, and all weathers. They include bus trips to
Valley Forge and to Longwood, the beautiful es-
tate of Mr. and Mrs. Pierre S. du Pont, a boat
trip on the Delaware, and visits to the Fairmount
and Rodin Museums and to the Historical Society
of Pennsylvania. The Museum authorities are de-
lighted to provide escort service for those de-
sirous of more than a passing glance at their
treasures, and the Historical Society will arrange
a special exhibition for the week, including por-
traits, prints, and engravings, documents, silver,
etc., from its unsurpassed collection of Americana.
There will also be a brief historic address by Dr.
Charles W. Burr, of Philadelphia.
Wednesday will be a field day — the big Aux-
iliary Luncheon — with guests and speakers from
the A. M. A. and a beautiful musical program,
the gift of the Delaware Auxiliary. In the after-
noon the Philadelphia County Medical Society in-
vites the women to be guests on a bus trip through
historic Philadelphia (a 10 minute stop at Inde-
pendence Hall), Fairmount Park and Germantown
to “Stenton”, where the New Jersey Auxiliary in-
vites us all to tea. “Stenton”, the home of James
Logan, Penn’s friend, Secretary of the Colony,
still stands just as it was built in 1728, the furni-
ture of the period, the garden laid out as described
by contemporaries. On Wednesday evening the
Pennsylvania Auxiliary invites all visiting ladies
to a reception in the superb Chinese Rotunda of
the University Museum, a setting probably un-
surpassed in any museum anywhere.
This meeting of the A. M. A. in Philadelphia is
the first in 30 years, and the County Medical So-
ciety, desiring to mark so auspicious an occasion,
and also in appreciation of the work of the Aux-
iliary, invites all members of the A. M. A. and the
visiting ladies to be its guests at a supper dance
in the Ball Room of the Bellevue, following the big
meeting of the A. M. A. on Tuesday evening at the
Academy of Music. The President’s ball at the
Benjamin Franklin Hotel on Thursday evening, to
which all are invited, will close the formal fes-
tivities.
To those still able to rise from their beds on
Friday morning there are offered a tour of Wana-
maker’s with luncheon in the Crystal Tea Room,
or an all-day bus trip to Atlantic City, where the
New Jersey Auxiliary will meet them for luncheon
at the Claridge. This program includes also a
visit to the new Convention Hall, an hour in a
chair on the Boardwalk, and plenty of time for
window shopping or a swim.
And finally, every day and all day there will be
a booth in the Roof Garden inscribed “As You
Like It" — Anywhere, where those wishing to golf,
shop, go to Garden Days, or carry out any other
pet project not elsewhere provided for, may find
information and assistance in making a profitable
use of their opportunity.
Will you not reward our efforts by the largest
and most enthusiastic women's attendance in the
history of the American Medical Association?
Atlantic County
Mrs. Maurice Chesler, Secretary
The last regular meeting of the Atlantic County
Medical Society Auxiliary was held Friday even-
ing, May 8, at the Chalfonte Hotel, Mrs. J. T.
Beckwith presiding.
At a public card party given at the Claridge
Hotel, Wednesday, April 29, the amount of $75
was cleared, and will be placed in the Welfare
Fund. Five-o’clock tea and refreshments were
served complimentarily by the Claridge manage-
ment. Mrs. James FI. Mason, 3rd, was in charge
of this party, assisted by an able committee.
Another delightful affair was held at the Clar-
idge on Wednesday, May 20, in the form of our
annual spring luncheon and bridge. Floral decora-
tions adorned each table and bird-nest plants were
given as prizes. Violin selections were beautifully
rendered by Mr. William Stokking, of the Clar-
idge Orchestra. Mrs. James H. Mason, Chairman,
was assisted by Mrs. J. T. Beckwith, Mrs. W.
Blair Stewart, Mrs. Robert A. Bradley, Mrs. Law-
rence A. Wilson, Mrs. James North, Mrs. Percy C.
Joy, Mrs. D. Wlard Scanlan, Mrs. Samuel L. Sala-
sin and Mrs. Maurice Chesler.
Mrs. J. T. Beckwith graciously welcomed 5 new
members to our Auxiliary, namely: Mrs. Henry O.
Reik, Mrs. Stanley M. McGeehan, Mrs. J. C.
Marshall, Mrs. Harry Subin, Mrs. B. B. Barab.
Interesting accounts were given by Mrs. James
North, Mrs. Percy Joy and Mrs. J. T. Beckwith,
who attended the Washington trip sponsored by
the Philadelphia County Medical Auxiliary.
Mrs. John F. Massey spoke of the coming con-
vention and arranged for her committee to assist
in receiving the national delegates and their
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
519
friends upon their visit to Atlantic City on June
12.
After the meeting' social hour and cards were
enjoyed.
Gloucester County
Reported by Mrs. Henry B. Diverty
The Woman’s Auxiliary to the , Gloucester
County Medical Society met Thursday evening,
May 21, at 9 o’clock, at the Woodbury Country
Club, the same hour and place of meeting of the
medical society.
The President, Mrs. Elwood Downs, was in the
chair, with the following members present: Mrs.
David Brewer, Mrs. William Brewer, Mrs. J. Har-
ris Underwood, Mrs. Oram Kline, Mrs. Henry B.
Diverty and Mrs. Downs, of Woodbury; Mrs.
Ralph Hollinshed, of Westville; Mrs. C. I. Ul-
mer, of Gibbstown; Mrs. Wandell, of Clayton,
Considering the heavy rainfall all day and evening
the attendance was fine.
After adjournment the ladies were invited to
hear Prof. Pennock, after which all partook of a
collation served by the Country Club chef.
Mercer County
Reported by Mrs. George N. J. Sommer
Delegates to represent the Woman’s Auxiliary
to the Mercer County Medical Society at the meet-
ing of the Auxiliary of the Medical Society of
New Jersey to be held at the Berkeley-Carteret
in Asbury Park, during the first week in June,
were elected at a meeting of the members on May
12, at the State Home for Girls. They are: Mrs.
D. Deo Haggerty, the president; Mrs. A. Dunbar
Hutchinson and Mrs. Alton S. Pell. The alternates
are Mrs. James J. McGuire, Mrs. D. M. Yazujian,
and Mrs. J. Otto Denelsbeck.
Plans were discussed for the tea to be given at
“Stenton”, the home of the late General Dogan,
in Philadelphia, by the Auxiliary to the State So-
ciety on Wednesday, June 10, in connection with
the meeting of the American Medical Association.
Preceding the meeting, which was arranged by
Mrs. G. N. J. Sommer, the members made a tour
of inspection of the school and classes while in
session. Mrs. Kate Burr Johnson, superintendent
of the home, entertained the members at tea fol-
lowing the session. There were about 30 present.
County Society Reports
ATDANTIC COUNTY
John S. Irvin, M.D., Reporter
The regular monthly meeting of the Atlantic
County Medical Society was held Friday night,
May 8, in the Chalfonte Hotel. The President, Dr.
Norman J. Quinn, called the meeting to order at
8.30 p. m. The Secretary, Dr. Joseph H. Marcus,
read the minutes and since there were no correc-
tions they were accepted as read.
Board of Censors : The applications of Drs. Rob-
ert Durham and Anthony Merendino were ap-
proved. The application of Dr. Van Delein for
Associate Membership has not been turned down
but merely is being held over until September as
he has not been practicing dentistry more than 8
months here and we are merely following a prece-
dent in not accepting a man for membership un-
less he has been in practice here for at least a
year.
Public Health and Sanitation : Dr. Stewart re-
ported that the State Board has investigated a
great many men and women here who are acting
contrary to law. They are always trying to keep
after these irregular practitioners. He said that
it was the duty of the members of the society to
report the names of these individuals who are
practicing illegally. Two names have been handed
to him recently.
'‘At our last gathering, jointly with the Council-
or District Meeting, we couldn’t take any action
on the death of Dr. George Scott. 1 want now to
say a word in regard to Dr. Scott. He was born
in New York City, in 1849, and graduated in medi-
cine in 1871. In professional work in New York
he was quite successful. As you all know, he was
a married man and had’ 2 sons. Unfortunately,
one was taken ill and died, and the second was
taken ill and on account of that boy’s health he
came to Atlantic City in 1903; and many of you
remember that in later years that son was taken
ill with pneumonia and subsequently died. It was
a great cross to Dr. Scott and his wife. Recently,
the doctor passed away at the age of 81 years.
I am glad to recall that in 1925 the Atlantic
County Medical Society honored him upon the
fiftieth anniversary of his graduation, and at the
same time honored Dr. Marvel, who had not quite
reached his fiftieth anniversary.”
Inasmuch as Dr. Scott was such an honored
member of our society I would like to move, Mr.
President, that a page be set aside in our Minute
Book in his memory. This motion was adopted.
Another member of our society is very ill in the
hospital — Dr. Thomas Taggart.
It was also moved and carried that a letter with
the society’s best wishes for an early recovery be
sent to Dr. Taggart.
Special Committee : Dr. Harvey reported that
the committee met and decided to enter the “Know
Your City Day Fair”. We have completed all our
arrangements and I believe we are going to put
over a very fine show. We are going to have a
lot of moving pictures. The lay people will un-
doubtedly ask a lot of questions and in order that
someone may be there to answer questions I feel
that some younger men should be there, or else
I wish some of the other men would volunteer to
stay there either a part of or a whole day.
The President asked Drs. Timberlake and Meren-
dino to stay in the booths on Monday.
A letter was received from Dr. Barbash in which
he acknowledged his appreciation to the society
on the courtesies extended to him on his wife’s
death .
A letter was also received from Mrs. Scott thank-
ing the society for the courtesies shown her on
the death of her husband.
The president announced that Drs. Mason,
Johnson and Reyner comprise the Entertainment
Committee for the June rrieeting, which is in the
form of an outing.
The president then introduced the speaker of the
evening. Dr. Joseph C. Doane, Associate Profes-
sor of Medicine, University of Pennsylvania Grad-
uate School of Medicine, who spoke on “The Etio-
logy, Diagnosis and Treatment of Diseases of the
End Arteries”. (To be published later in the
Journal.)
520
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
Atlantic City Hospital Staff
Joseph H. Marcus, M.D., Secretary
The regular monthly meeting of the Atlantic
City Hospital Staff was held April 24, with the
president, Dr. Milton S. Ireland, presiding.
The scientific program was opened by Dr.
Gerald A. Cyr, who spoke of “Barbituric Acid
Derivatives and Their Toxic Manifestations”.
Much has been written about the therapeusis
of the barbituric group of acids, but strange to
say very little work has been done, or should I
say reported to date, regarding toxicity. In an
effort to obtain the best information regarding
this topic, I wrote to the American Medical As-
sociation and am allowed to use the various
clippings and articles collected relative to this
matter. Even then I found it very difficult to
correlate the material because all the articles
dealt mainly with the toxic effects of 1 or 2 of
these acids chief among which were the toxic ef-
fects of barbital itself. Finally, I wrote to the
Eli Lilly Company, but was again discouraged by
finding no literature on the relative toxicity of
the barbituric group of acids.
Just a few words might be said at this time
about the chemistry of this group of acids. That
part of the barbituric acid residue which is re-
sponsible for the production of sleep is of interest.
Urea is capable of acting as a hypnotic only when
combined with radicals rich in carbon, and it is
most effective in the cyclic arrangement found in
barbituric acid. Dox believes that to induce hyp-
nosis without extreme untoward effects, the mole-
cule must possess substituents on the number 5
position, which is the methylene group of the
melannic acid radical.
Few, if any, of the reports dealing with a deriv-
ative of barbituric acid have included descrip-
tions of all the associated toxic symptoms, but I
have included the toxic symptoms which have
been described.
(1) Cutaneous Rash. Littenfield, in 1903, pointed
out that one disadvantage of diethyl barbituric
acid was the erythema which it might produce;
similar to that of antipyrene. A case is reported,
where a man took 4.25 gm. in 2 days and 8.5 gm.
in 3 days, with the following manifestations:
erythematous rash; tenderness in the region of
the right mastoid process; discharge from the
right ear; temperature 101°; pulse rate 125; de-
lirium and semicoma: but recovery was prompt
after the drug was stopped. In 1907, House re-
ported on cutaneous eruptions after a dose of 1
gm. diethyl barbituric acid. He also pointed out
that cutaneous eruption is the most constant
symptom following all but the most rapidly fatal
dose. Tardieu pointed out that the rash usually
appeared only in subacute cases or during con-
valescence from severe poisoning, and generally
constitutes favorable prognosis.
Blamoutier reports the case of a woman who
took several doses of diethyl barbituric acid with-
out any symptoms; 5 months later, she took 5
gm. the same drug and an erythema developed;
15 months later she took 20 drops of somnifene
and in 10 minutes erythema and edema of the
face and buccal mucosa developed. This illus-
trates the danger of giving any other derivative
of barbituric acid to a patient who already has
shown intolerance or sensitivity to one member
of the barbituric group.
Coma. Symptoms of a serious overdose are coma
and stupor. Many cases have been reported.
Farncomb reports a case where a woman was
totally unconscious for about a day; in 2 days
temperature was 102° with anuria; next day tem-
perature 103°, pulse rate 160-180, and consolida-
tion was beginning at the bases. Fever soon rose
to 104° and the lungs became totally congested.
The temperature continued to rise at the rate of
V2° every % hour until it reached 107° by axilla,
and death occurred. This brings out a point, the
so-called barbituric acid fever, which may be the
result of pulmonary congestion, and only indi-
rectly due to the drug.
Eye. Pupillary changes may be observed from
diethyl barbituric acid poisoning. Reports of
cases of acute poisoning show that the lethal
dose varies from 30 to 200 grains. A patient took
150 gr. and was comatosed for a few hours.
There was complete muscular relaxation and
abolition of all tendon and cutaneous reflexes;
pupils were fixed and did not react to light or
accommodatioin ; Cheyne-Stokes’ respiration de-
veloped. The following day there was evidence
of congestion of both the lungs, a cutaneous erup-
tion developed, and the patient died. It is evi-
dent from one of these reports that ocular phe-
nomena are incident to poisoning from barbituric
acid but these signs are not pathognomic of poi-
soning from barbital and only call attention to
the effects of these drugs on the reflexes.
Farnell, in 1913, reported 2 cases in each of
which it was evident that action of the drug did
not manifest itself until the cumulative effect
had set in. He pointed out that 5 gr. luminal has
about the same action as 8 gr. veronal. In 1925,
Weig reported a case of fatal poisoning by this
drug. A woman, 67 years of age, suffering from
arteriosclerosis, died 39 hours after she had tak-
en 15 gr. luminal. This should call attention to
the decreased tolerance of those of advanced age.
Many cutaneous eruptions have been reported
from large doses of luminal.
Hang, in 1919, reported 2 cases of epilepsy in
which 1 % gr. of luminal t.i.d. had been pre-
scribed. In 4 weeks in 1 case, and 11 days in
the other, from the time that this treatment was
begun, the patient suffered from high fever, diar-
rhea with mucous stools, and eruption resem-
bling scarlet fever covering the whole body except
the hands and face. The total amount taken by
first patient was 12 6 gr. ; the second 50 gr. The
first patient was slightly stuporous, the second
had albuminuria. After suspension of the drug,
the symptoms subsided in a few days.
Rutonal is closely related to luminal and both
have been used clinically with about the same
results, and their toxic effects are about the same.
Dial has produced toxic effects. Zuelehour, re-
porting on the administration of 800 doses of
dial to 25 patients, noted transient vertigo, but
observed that a rapid tolerance to dial develops.
Christofel, in 1918, pointed out that 3 gr. of dial
is equivalent to 8 gr. veronal and 30 gr. chloral
hydrate. Buc-hel, writing on poisoning from dial,
pointed out that death is due to respiratory par-
alysis and that the cardiovascular system is lit-
tle affected. He felt that fewer cases of poison-
ing from this drug had been reported and that
the essential signs of poisoning from dial are
slight dyspnea and coma.
Somnifene. Zaffison reports upon a man 24 yr.
of age who took 2.4 gm. of the drug and was un-
conscious for 24 hr. with complete retention of
urine which persisted for another 24 hr. He was
treated with gastric lavage and salt solution, and
recovered in 3 days without complications. He
believes that this drug should not be used for
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
521
postoperative pain as it increases the percentage
of postoperative thrombosis.
Amytal has been used in large and small doses
with results comparable to the other derivatives
of barbituric acid. It has been uniformally ob-
served that in overdose it lowers the blood pres-
sure; particularly true in cases where there is
arteriosclerosis and hypertension. Some men
have called attention to the advantages and dis-
advantages of amytal. The extreme quietness
following operations increases the likelihood of
postoperative pneumonia or massive pulmonary
collapse. There can be no question that when
excitement or pulmonary complications follow
the use of amytal, too much of the agent has
been used or the blood pressure has been lowered
to a critical point.
The clinical lesson which one should learn
from this short review is that the speed with
which a derivative of barbituric acid takes ef-
fect depends on the route of administration of
the drug. However, and this is the important
factor, the depth of hypnosis or the anesthesia
produced is not essentially based on the route
of administration, but on the dose used. If a
dose larger than the hypnotic one is to be used,
then it is safer to follow the intravenous method;
otherwise, it is safer to use divided doses.
In conclusion, allow me to emphasize the fol-
lowing important points; (1) One must remem-
ber that all derivatives of barbituric acid are as
potent to do great damage as they are to do good,
if given in too large doses. Fatal results have
resulted from overdose of each member of the
group.
(2) One must keep in mind that to adminis-
ter the drugs daily for a long period of time
might result in poisoning due to the cumulative
effects, especially barbital, which is only slowly
eliminated from the body.
(3) One must also remember that a patient
can easily become sensitized to the drug, and that
to re-administer the drug to him at a later date
might produce in him an anaphylactic reaction.
(4) Finally, that no 2 patients will respond
in the same manner to these drugs, each patient
being a problem in himself, and that it then be-
comes the duty of the physician to carefully
watch his patient for the slightest evidence of
intoxication.
Dr. Louis .Downs spoke of “Sodium, Amytal and
Its Chemical Uses, with Especial Reference to
Value as a Pre- Anesthetic Agent''.
Before going' into the chemistry, I would like
to review the general pharmacologic features
of sod. amytal and other barbituric acids.
(1) Barbituric acids are primarily hypnotics;
only occasionally will hypnotic doses produce
analgesia or anesthesia.
(2) There is a marked variation in effect, and
selection of proper dosage is difficult.
(3) Doses that will cause deep hypnosis may
seriously embarrass the respiratory and circula-
tory systems.
Amytal and neonal are not recovered in the
urine. Intravenous injection of as much as 22 gr.
amytal failed to give traces in urine; evidently
amytal is completely destroyed in the body.
Opinion is divided as to the carbohydrate me-
tabolism, some stating that hyperglycemia and
glycosuria follow administration of amytal; while
others find no effect. Animals with high blood
urea showed no untoward effects from amytal
and the dosage needed was less — indicating that
the drug does no harm to the kidneys. Patients
receiving amytal as a pre-anesthetic took fluids
more freely the following day and nausea was ab-
sent, or rather they had greater freedom from it.
When injected intravenously the induction of
sleep is rapid and quiet. Drowsiness, yawning
and slurring of words come on after administra-
tion of 3-9 gr. Increase in dosage causes reflex
hypersensitiveness but finally produces profound
narcosis. Patients are very restless and time is
required before patient is calm and reposed. This
narcosis lasts from 3-6 hours. Afterward they
are drowsy, but are cooperative in taking fluids..
Patients who have experienced other opera-
tions under ether claimed that sod. -amytal made
their present operation a pleasure in contrast to
the previous one. For exophthalmatic goiter and
other apprehensive excitable patients, amytal has
a definite place in anesthesia.
Mason and his associate call attention to the
individual susceptibility; dosage ranging from 3-9
gr. in their report. Old debilitated patients fall
asleep with 3-5 gr. and robust patients need 7-9
gr. From their observations in 305 cases, the
patient slips away into a sleep that certainly,
to all appearances, resembles physiologic sleep.
In only 1 instance was there any evidence of ex-
citement during the induction of sleep by sod.-
amytal or by the later induction of deeper anes-
thesia by inhalation anesthetics.
Lundy used it oralis^ in doses of 6-9 gr. in 73 0
cases and observed little if any nausea or de-
lirium and there were no respiratory difficulties.
By intravenous route he used it 457 times to pro-
duce part or all of anesthesia. He calls atten-
tion to the rapid injection of the drug and fol-
lowing large doses he observed delirium, edema
of lungs, pneumonia and inability to raise mucus
after thyroidectomy and stated these as an ob-
jection to the use of the drug as a sole anes-
thetic.
The uses of this drug, other than pre-anes-
thetic, inclyde the control of convulsions from
any cause.
Dr. V. Earl Johnson reported the Surgical Ser-
vices of Dr. Thomas Taggart and himself for
the months of November and December 1930,
and January 1931.
During this tour of service, of approximately
3 months, there were admitted 19 0 patients. Of
this number, 9 3 were of traumatic origin; or
approximately 50%; 133 operations were per-
formed. There were 17 deaths this year, or about
9%, as compared with an 8% mortality rate
last year; 10 of these deaths occurred with pa-
tients who had been operated upon — a post-
operative death rate of approximately 7.5%, as
compared to an 8 % rate, last year.
The question of choice of anesthesia on our
service has been given considerable care and it
has been interesting to make a comparative study.
A tabulation shows that we used: Nitrous oxide
with ether, 14 times; nitrous oxide alone, 40;
spinal anesthesia, 22; avertin — either alone or
combined with nitrous oxide or local, 14; local
field block or local infiltration, 15; chloroform, 2;
ether-oil colonic, 1; sodium amytal preliminary,
5.
Dr. Robert A. Kilduffe, Director of Pathologic
Laboratories, presented his report for 1930, which
comprised a total of 45,305 reports made. The
volume of work can best be appreciated by esti-
mating its book value, amounting to $132,930, an
increase of $25,706 over 1929. In addition to’the
laboratory work done for the hospital as an en-
tity, work was also performed for the Municipal
Hospital, Betty Bacharach Home, Board of
Health, Asylum, Almshouse, and Pine Rest.
522
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
There were 19 publications issued by Dr. Kil-
duffe in various journals in the United States
and abroad.
BERGEN COUNTY
C. H. Littwin, M.D., Reporter
About 35 members attended the regular month-
ly meeting which was held at Bergen Pines by
invitation of Dr. Morrow. The minutes of the last
meeting were read and approved, as were also
those of the Executive Committee.
Dr. Kilts reported for the Credit Protection
Committee, that he fejt the only satisfactory
credit bureau would be one organized and super-
vised by the physicians themselves. He will sub-
mit a proposition for consideration at the next
meeting.
The Public Relations Committee announced
through Dr. Wolowitz that the broadcasting has
come to an end for this year; he also stated that
the Post-Graduate Course is proving very suc-
cessful; 31 men taking it.
Drs. Wilson and Pallen spoke on the proposed
organization of a Cancer Clinic.
Dr. Levitas spoke of the difficulty in arranging
a program for the June meeting, which conflicts
with the A. M. A. Convention, and at his sug-
gestion a straight business meeting was ordered.
Dr. Neil McLeod Whittaker was elected to
membership. Dr. R. M. Anderson, a former
member, was reelected by transfer from the
Minnesota Society. Dr. Frank L. Niles, of Hack-
ensack, was elected by transfer from the Lacka-
wanna County Society of Pennsylvania.
The applications of Joseph Bono, of North-
vale; Luke A. Mulligan, of Leonia; and Herman
Feit, of Hackensack; for associate membership,
were read.
The death of Dr. Max Wyler, of Fort Dee, form-
erly president of the society, was reported. A
motion was adopted that the President appoint
a friend to draw up resolutions for the society to
adopt.
The proposed County Laboratory was endorsed
by the society.
Dr. Levitas introduced Dr. Reuben Ottenberg,
Associate Physician of Mt. Sinai, who spoke at
Length on “Diseases of the Liver and Their Treat-
ment’’. His talk opened up many new concepts
of liver conditions which are now being unfolded
by research workers. Many new tests of differ-
ent liver functions are being developed, and these
he explained. It is certain that a great deal
more attention will be focused on this important
organ in the future, both from the viewpoint of
tests for incipient disease and for treatment.
Second Councilor District Meeting
(Reported by the Councilor, Dr. Snedecor)
The delegates and officers of Hudson, Sussex,
Passaic and Bergen County Medical Societies met
for dinner at the Oriental Club, at Hackensack,
April 29.
This meeting, admittedly an experiment, brought
together 37 representatives of these medical groups.
All of these men were empowered with the re-
sponsibility to carry back to their constituencies
the proceedings in which they all had an oppor-
tunity to take part and then to carry them for-
ward to the State Convention.
Dr. Harry Perlberg, Secretary of the Hudson
County Society, presided. Dr. Spencer T. Snede-
cor, as Councilor for the district, welcomed the
group to Hackensack. A brief talk on the oppor-
tunities for constructive action by this group was
given by Dr. Quigley, Third Vice-President of the
State Society.
The first topic on the program was introduced
by Dr. Coleman, of Sussex: “Shall the Physicians
Seek to Amend the Hospital Lien Law to Include
Doctors and Nurses?’’ This was forcefully dis-
cussed by Drs. Poliak and Kuhlman. Dr. Quig-
ley’s motion was passed, without a dissenting voice,
as follows: Resolved that the Welfare Committee
of the State Society be urged to secure, if possible,
at the coming session of the legislature an amend-
ment of the hospital lien law to include doctors and
nurses.
Dr. Waters, of Hudson, presented a careful re-
sume of the attitude of other states, Canada, and
Europe, on the “Problem of Licensing Specialists”.
He then submitted a carefully thought out plan for
proper accrediting and control of specialists and
specialism by the State Medical Society. In prin-
ciple, this was heartily approved and was felt to
deserve consideration by the State Society. It was
discussed by Drs. Kelley, Littwin, Schwarz and
Levitas. It was moved that the plan be referred
to the Welfare Committee of the State Society
with the request that a special subcommittee be
appointed to consider it and report next year.
Dr. Joseph R. Morrow, of Bergen, opened a
discussion on the “Supervision of Public Health
Nursing”, and was followed by Drs. Knox, Mar-
ris and others.
“The Need for Better Public Relations Through
County Medical Society Publicity” was spoken of
by Dr. Spencer T. Snedecor, of Bergen. This was
discussed and the following motion passed: Re-
solved that the State Medical Society be asked
to appoint a special committee for the promotion
and supervision of county society publicity.
Dr. Harry Perlberg, of Hudson, spoke on the
problem of “Medical Charity”. He was closely
seconded by Dr. Hasking who spoke at length on
the new state poor laws, which make the medical
care of the poor a direct municipal responsibility.
He said he felt that most of the problems of free
medical service would be worked out by municipal
payments.
Dr. Wilbur, of Sussex, presented for considera-
tion a “Plan for Continuing Immunization Against
Diphtheria”. When a certain percentage, possibly
SO to 90%, of the children have been immunized
in a school, it should be made a requirement for
admission, and the immunization should be done
by the family physician.
Dr. Wayne Hall, of Passaic, discussed the sub-
ject of “Preschool Examinations”, and urged the
need for a campaign to encourage this work.'
When the meeting adjourned it was felt that a
great deal of fruitful discussion had been held on
topics which are of vital interest to the general
profession. More than that, many new friends
were made among the delegates of other societies
whom we expect to meet again at Asbury Park
in June.
Plan for Proper Accrediting and Control of
Specialists and Specialism by the State
Medical Society
(I.) Formation of a State Society Committee
on Credentials for accrediting members for special
practice, with subsidiary county committees to re-
fer approved applicants to the state committee
for action. These committees might be formed as
follows: State — President, ex-officio, the Chair-
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
523
man of the Welfare Committee. Chairman of Pub-
licity Committee, Chairman of Board of Trustees,
and member of the State Examining Board.
County — 12 members, with the president ex-
officio; the members to be chiefs of departments
or ranking attendings in their respecitive hospi-
tals, and members of the colleges or groups now
nationally accrediting physicians for special prac-
tice, apportioned as follows: Surgery 2, Medicine
2, Obstetrics 1, Eye and Ear 1, Nose and Throat
1, Roentgenology 1, Genito-Urinary 1, General
Practice 1, Gynecology 1, Pediatrics 1.
(II.) Requirements for Acceptance as Special-
ists:
(1) Those accepted by the respective groups of
specialists gathered under the following Societies
and Colleges:
(a) American College of Surgeons.
(b) American College of Physicians.
(c) American Society of Obstetricians and
Gynecologists.
(d) American Boards of Otolaryngology and
Ophthalmology.
(e) American College of Radiology and the
Radiologic Society of North America.
(f) American Society of Psychiatrists.
(2) Accrediting by Recognition of Experience:
(a) Men in practice longer than 10 years who
have been notably identified with certain branches
of medicine and surgery and who are accepted in
their communities by their fellow practitioners as
competent in the field to which they are giving
special attention.
(b) Men in general practice, holding a hospital
service in a special branch of medicine, which ser-
vice is sufficiently active to allow of attainment
of a high degree of proficiency in that branch of
medicine. The duration of appointment must be
not less than 5 years.
(c) Properly qualified and trained men, not
classified in (a) and (b). Those of ample hospital
and post-graduate training in practice 5 years or
more, who furnish proof of qualifications which
are acceptable to the State Committee on Cre-
dentials.
(III.) Distribution of Information Regarding
Accrediting of Members for Special Practice and
those so Accredited:
(1) Newspaper notices, prepared by County
Committee on Credentials and certified by the
State Commjttee on Credentials.
(2) Radio talks; best through the State Com-
mittee.
(3) Through agency of the medical profession;
office placards and pamphlets on the subject of
“Choosing a Specialist’’.
(4) Display of Certificate issued by the State
Society through the State Committee on Creden-
tials for Special Practice.
(5) Distribution of information through a Cen-
tral Information Office in each county medical
district; (a) Physicians’ and Surgeons’ Telephone
Exchange; (b) Secretary’s Office of the County
Society.
BURLINGTON COUNTY
Roscius I. Downs, M.D., Reporter
A regular meeting of the Burlington County
Medical Society was held in the Community
House, Moorestown, Friday, May 15. The Presi-
dent, Dr. Joseph M. Kuder, called the meeting to
order at 2.15 p. m. by asking all present to take
their places at the dinner table and join in the
repast.
Dr. Kuder asked the guests to arise when he
announced their names, as follows; from the
Bucks County Medical Society, of Pennsylvania—
Drs. W. M. Le Compte, J. F. Wagner, James Col-
lins, Joseph Abbott, Frank Lehman and Miss
Lehman; Drs. John C. Hurst, P. Brook Bland and
R. P. Andrews, of Philadelphia,; Dr. Frank Wood,
resident physician at the Burlington County Hos-
pital.
Immediately following dinner the minutes of
the March meeting were read and approved. The
Secretary reported that return questionnaire
postcards had been sent to all members of the
society, requesting an expression of opinion on
the following questions: Do you prefer that meet-
ings of the society be held in the Burlington
County Hospital or elsewhere in various com-
munities in the county? — Do you prefer that
scientific papers be presented by outside men or
by members of the society? — If you prefer the
latter, will you present a paper if requested to
do so ?- — Do you think a meal a desirable adjunct
to meetings? The Secretary reported that of the
5 0 cards sent out, 34 had been returned, which
tallied as follows: 13 in favor of meeting at the
Burlington County Hospital; 17 in favor of meet-
ings elsewhere; 22 were in favor of having men
from outside the county present scientific papers;
22 thought a meal a desirable adjunct to a meet-
ing.
The Board of Censors having reported favor-
ably on the application of George J. Wagner, of
Delanco, he was elected to membership.
Dr. Eugene A. Meyer, of Moorestown, who had
been elected to membership at a previous meet-
ing, signed the constitution of the society after
having responded affirmatively to the declaration
made by the President, Dr. Kuder, to comply
with the constitution and by-laws of the society.
Dr. Kuder announced for the Woman’s Aux-
ilary that a dinner dance and card party would
be held at Log Cabin Lodge, Medford Lakes, on
Tuesday, May 26, at 7.30 p. m.
The Burlington County Auxiliary has a very
active and efficient organization and its members
have expressed eagerness to cooperate with the
society in any suggested work. Dr. Kuder sug-
gested in matters of health education particularly,
in which the physician with grace and propriety
cannot extol the value of his own services, the
auxiliary may render noteworthy service in ar-
ranging meetings between the public at large and
the medical profession.
It was regularly moved and seconded that the
president appoint a committee of 3 or 5 to be
known as the Public Relations Committee.
The secretary reported that the Fourth Coun-
cillor District Meeting, held at Lakehurst on
May 1, had the largest attendance of any of the
district meetings in the state, there being 170
present. The combined social outing with an in-
structive scientific evening, by our host — The
Naval Medical Corps — was well worth while. Such
meetings should make for more widespread
acquaintance among the members of the profes-
sion in Burlington, Camden, Monmouth, and
Ocean Counties, and thus better the fellowship
at the Annual Meeting of the State Society.
Dr. Edward R. Hunter, Chairman of Section
Gynecology and Obstetrics, announced the pro-
gram, and introduced Dr. John Cooke Hirst, of
Philadelphia.
Dr. Hirst, after an impromptu talk on sterility,
demonstrated by manikin the contraceptive tech-
nic used by the Maternal Welfare Clinic at 69th
524
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
Street, Philadeljahia. He said that many patients
from New Jersey were coming to the clinic and
that no one was treated unless she presented a
note from her physician requesting it. Dr. Hirst
thought the physicians in New Jersey should take
up the matter of opening a clinic in this state.
Dr. P. Brook Bland, of Philadelphia, demon-
strated by moving picture film the “Trichomonas'’
with discussion of the most frequent gynecologic
symptom, leukorrhea, and certainly presented his
subject in a most interesting and instructive man-
ner. Leukorrhea is a symptomatic expression
of a disease, with variable clinical characteristics,
and is usually treated in an unscientific manner.
Trichomonas is quite prevalent in the colored
race. Usually the patient has very little distress
except the bubbling, yellowish discharge. Diag-
nosis of the parasite can be confirmed by the
microscope. The exact pathology is not yet
proved and the source of infection is not known.
The parasite has never been found in the intes-
tinal tract. The important point in treatment is
mechanical cleansing by vigorous scrubbing of
vaginal mucous membrane with tincture of green
soap, a vaginal douche of Lugal’s solution and
water at night, followed by an alkaline douche in
the morning.
Drs. Bland and Hirst were given a vote of
thanks from the society.
The society adjourned to meet in September,
there having been 31 members and 9 guests pres-
ent.
CAMDEN COUNTY
Robert S. Gamon, M.D., Reporter
The regular meeting of the Camden County
Medical Society was held in the City Dispensary
Building, Tuesday, May 5, 1931, at 9 p. m., with
Dr. W. J. Barrett presiding.
The scientific paper of the evening was pre-
sented by Dr. Frank C. Benson, of Hahnemann
Hospital on “Radium in Prostatic Pathology”.
The essayist gave a most instructive discourse on
radium and radio-activity and then gave the re-
sults of his clinical and experimental work with
radium in prostatic pathology. The paper was
discussed by Drs. A. H. Lippincott, D. F. Bentley,
Jr., and Albert Bothe, by invitation.
The Committee on Public Relations presented a
report which was accepted by the society. Its
recommendation included the establishment of a
Public Speaker’s Bureau, sponsored and endorsed
by the county society and consisting of members
of the society who would be available to address
public gatherings. The committee reported nega-
tive findings on newspapers and radio publicity.
The next meeting of the Camden County Medi-
cal Society will be held in conjunction with the
annual outing of the combined societies of Cam-
den County. The date has not as yet been an-
nounced.
The meeting was well attended.
ESSEX COUNTY
E. LeRoy Wood, M.D., Reporter
The economic problems of the physician con-
tinued to hold attention of the Essex County
Medical Society at its meeting held Thursday
evening, May 14, at the Academy of Medicine, 91
Lincoln Park, Newark.
Dr. Charles Gordon Hayd, President of ihe New
York County Medical Society, spoke on “Modern
Medical Problems and the Practitioner”. He
pointed out that physician’s fees play a very small
part in the high cost of medical care, a subject
being featured in many lay journals. He said that
a report would shortly be rendered by a com-
mission studying the “High Cost of Medical Care”
showing that the bulk of medical expense goes for
medication (especially patent medicines), nursing
and institutional care, and laboratory examina-
tions, but a relatively small proportion to the at-
tending physician. He suggested that the ex-
pense of laboratory diagnostic aids be reduced by
greater use of the physician’s own abilities. An
accurate diagnosis can generally be reached after
adequate use of the 5 senses and a good history
of the illness. He said: "The fundamental object
of medical practice is to provide and make avail-
able adequate, effective and efficient medical ser-
vice at all times for every member of the com-
munity, regardless of race, color or creed. Medical
service as provided today is in a large measure
effective and efficient although not always ade-
quate or available. The payment to physicians
for medical service is not a large item in the so-
called cost of medical care, as only about 50% of
patients hospitalized in general hospitals pay a
doctor’s fee. There is no logical reason for be-
lieving that the professional item for adequate
and effective medical service can be materially
lessened or reduced. On the contrary, there are
many reasons for believing that it will be in-
creased. The doctor is a citizen and must dis-
charge all of his obligations of citizenship the same
as any other member of the community. The
doctor is entitled to a monetary return for his
labor that is fair and commensurate with his ser-
vices, training and experience. The fact that the
practice of medicine is a profession does not mean
that the doctor shall continue to work under a
system that is ethically wrong and economically
unsound. The doctor must be paid for his ser-
vices in order to function as a useful and con-
tributing member of society. These postulates
present the background and serve as an introduc-
tion to considering what is the economic contri-
bution of physicians to the community. Physi-
cians annually contribute to the community $365,-
000,000 worth of free medical service. It is claimed
by competent statisticians that physicians treat y8
of the population of the United States free of
charge. Since at all times 2% of the population
is incapacitated and about 4% physically impaired,
it follows that from 375,000 to 500,000 persons are
daily treated without charge. If only $2 per per-
son were charged for treatment, the sum total
monentary equivalent for contributions annually
made by physicians in the form of free medical
treatments would be $365,000,000. If all the medi-
cal and quasi-medical foundations were consoli-
dated into one organization their entire contribu-
tion to society in dollars during the last 20 years
is not equal to the annual donation of the physi-
cians of the country. The medical profession may,
therefore, justly claim that under the present
medico-social system it stands without a rival
in the entire field of medical charity and health
philanthropy. This immense philanthropic enter-
prise is created by the labors and services of
150,000 physicians working for an average re-
muneration of $3000 per annum.
The average doctor today is about 28 years of
age before he begins practice. What has it cost
in actual dollars to produce this educated and
trained product? His premedical and medical edu-
cation will certainly cost, with fees, maintenance
and miscellaneous expenses, $16,000. His loss of
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
525
earning capacity while being professionally edu-
cated may be estimated roughly for 6 years as
$12,000. This young man then begins practice
with an estimated indebtedness of $28,000 upon
which he should pay $1400 a year as interest. I
seriously doubt, although I have no figures to
verify it, whether 80% of the doctors ever over-
come this primary indebtedness. In other words,
more than 4/5 of our profession never repay their
capital investment by leaving an estate equal to
$28,000 and never make up the carrying charges
by annual savings of approximately $1400. To
just break even the doctor must logically pay this
interest and create a capital of $28,000 before he
dies.
That the medical service provided by doctors
in the last 30 years has, cn the whole, been effec-
tive is indicated by a study of the mortality rate
in 1900 as compared to the mortality rate in 1925.
If the medical service given to the middle class
(white collar) had been ineffective or inadequate,
then we should expect to find that the people suf-
fered from such service. This is not apparent
because the decline in modern mortality is im-
pressive. Mr. Wolman has calculated that,
based on the death rate obtaining at the be-
ginning of the century, in 1925 there would
have died 1,962,999 persons, but actual deaths were
only 1,389,673 persons, a saving of 573,326 lives.
With only 43% of the community gainfully em-
ployed and 87 % of the community receiving less
than $2000 a year, no matter how much the cost
of medical service can be reduced, it cannot be
brought sufficiently low to allow this large group
of the community to pay for medical service with-
in its income.
More is spent on nonessentials than on medical
care. The costs of cosmetics, cigarettes, and
chewing gum are expenditures that are in no
sense necessities and are distinctly in the luxury
class. These luxury expenditures total over 5 %
times the total cost of all nongovernmental health
services. The amount spent for tobacco alone is 3
times as much as that spent for physicians, and
the American people spend more for candy than
they do for doctors.
There are other economic disabilities that are
enforced on the doctors as against the other pro-
fessions. The establishment of a free clinic by a
I philanthropist, without the employment of paid
physicians, is a most unphilanthropic act. Such
an individual is forcing other sick people who are
already burdened with debts and whose incomes
have stopped, to hire and pay doctors who attend
the patients in the free clinic. No free clinic
should be permitted to operate without reimburs-
ing the attending physicians for their time. It
would be a splendid move in social medical ad-
justment (1) to curtail the unrestricted system of
gratuitous relief, by excluding those not entitled
to gratuitous medical advice; (2) to insist on pay-
ment of the medical staff engaged both in clinic
and out-patient work, and the payment of fees by
patients in the pay ward and in the consultation
departments of voluntary hospitals. If the doc-
tor could be assured of, let us say, a minimal
revenue from all the patients whom he takes care
of, he could well afford to permit a reduction on some
percentage of his work. But what is attempted,
if one may judge from recent newspaper publica-
tions, is to oblige the doctor to continue his free
medical service and at the same time accept a
reduction in his charges to patients whom he takes
care of and who are occupying certain types of
rooms which are essentially private hospital ac-
commodations.
Dr. Henry C. Barkhorn, President of the Essex
County Medical Society, presided. He asked the
support of the profession for the Society for Re-
lief of Widows and Orphans of Medical Men, an or-
ganization making an immediate payment to the
members’ widows and supplying aid, on request,
to any needy widow or orphan of a medical man.
The following new members were elected: Drs.
Gordon P. Goodfellow, Aaron H. Horland, Harry
A. Lowenstein, Prank W. Senna, and Ernest Tut-
schulte.
An organization meeting of the county delegates
to the state society followed, which lasted to a
late hour.
Prior to the meeting, Dr. Barkhorn entertained
the delegates and alternates at dinner.
Academy of Medicine of Northern New Jersey
Eye, Ear, Nose and Throat Section
E. LeRoy Wood, M.D.. Secretary
‘ The meeting of the Eye, Ear, Nose and Throat
Section of the Academy of Medicine of Northern
New Jersey held Monday evening, May 11, was
planned to celebrate its organization 20 years pre-
viously. The founder members and past officers
were specially invited to attend. The Chairman,
Dr. J. Wallace Hurff, presided.
One of the original members, Dr. Charles W.
Buvinger, read the minutes of the first meeting,
enumerating and recalling the founders and giving
a verbal sketch of each.
I)r. Fred Weiner , the first secretary, recalled the
early days of the society and traced its progress.
Dr. Wells P. Eagleton, President-Elect of the
Academy, made helpful recommendations for the
conduct of the society during this coming year.
He suggested that 2 of the 8 meetings, of the year
be bedside clinical meetings, and that the meetings
be held at different hospitals having instructive
clinical material.
This suggestion was favorably commented on
and accepted for future consideration and action.
Dr. Henry C. Barkhorn recommended that this
section of the Academy engage in an organized
teaching program for the benefit of its members,
tie said:
“We must realize that a new group of young
men is growing up in our midst. A group of men
who have taken post-graduate work, who are bet-
ter prepared in just those things in which we are
weak; a group with a ‘show me’ attitude, and we
must meet our responsibilities. There are in-
numerable opportunities for teaching. We are all
a little weak in anatomy and to someone might
well be assigned the task of summarizing each of
the special fields for us. In pathology we are even
weaker and still the literature is full of patho-
logic findings ail'd descriptions.
It might be well to have a subsection of just
those who are really interested to meet once a
month, either here or in successive homes, to sum-
marize the preceding month’s literature and new
books for criticism and discussion. I am sure I
would be glad to join and do my part of the work.
A cadaver could be procured and shown at a
meeting to demonstrate operative procedures. The
first night could be given to the more massive
operations such as mastoids, simple radical and
classical labyrinth, followed by Eagleton’s unlock-
ing of the petrous tip, a cerebellar and subtem-
poral decompression, a frontal and antrum, with
some eye operations such as the Kronlein and an
evisceration of the orbit. The next night, for a
smaller group, could be devoted to intranasal
526
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
manipulations, lachrymal sac operations and sur-
gery of the neck; and a final, third night, on pig
eyes, to a still smaller group for cataract opera-
tions, etc. I emphasize the smaller groups be-
cause I am sure the crowd would dwindle down.
The one thing that is really painful to the av-
erage present day doctor, as to the lawyer, business
man, and all modern Americans, is hard work, and
1 suggest these things with fear and trepidation
because I feel that if in the future as in the past
we are to continue to be leaders in ophthalmology,
otology, rhinology and laryngology in this vicinity,
our work is never finished and we must go on not
only developing our own fields but enlarging them,
correlating the advances in other fields to ours,
making more surveys of the entire body, clarifying
our information, appreciating our pathology, learn-
ing to apply proper therapy and operative proced-
ures, and crystallizing the facts.
This group should be the clearing house for all
these matters. It should sponsor courses such
as those by Brunner and Spiegel. When Brunner
gave his course the enlarged mailing list of this
section was used for prospects. We should, how-
ever, tell these teachers exactly what we want
and not let them spin their work out interminably
with a lot of padding.
We need a didactic night on sinus thrombosis,
one on the labyrinth, 1 on the cerebellum and 1
on the petrous tip, but only 1 on each of these
subjects, and if properly condensed and tabulated
they could easily be put across.
We have been peculiarly fortunate in being the
first-born of the sections of the Academy. We
have carried on the traditions of the Academy with
more success than most of the other sections. We
have done more with and by our own men, it
seems to me, than any of the other sections, and
this is what the Council most desires. I know,
for I have been on it for many years. We have
been proudest of the accomplishments of our out-
standing members and have made special efforts
to give them ample opportunities for self-expres-
sion and to bring to us that which they have
learned. We have cemented old friendships and
developed new and firm ones. This section has
done much in letting us know others who have
similar tastes in medicine and in fostering those
friendships which are formed because of the
strong personal interest of its members in the
advancement of our specialty.”
Dr. Erwin Reissman, the retiring President of
the Academy, recommended that most of the sec-
tion program be developed from local talent, from
our own members.
Dr. J. Wallace Hurff then installed the new
Chairman, Dr. Charles W. Buvinger, and there
followed a discussion of the future meetings.
Dr. Elbert S. Sherman suggested the utilization
of more clinical material, that better facilities be
provided for the proper showing of patients, and
that the cases be fully listed on the program.
Dr. George J. Holmes suggested that an informal
“dutch treat” dinner for all interested be held be-
fore the meetings and that there be teaching
courses.
Dr. Dennis O'Connor suggested that the meet-
ings begin earlier and on time.
About 35 were present.
The Academy of Medicine of Northern New Jersey
Adrian Ralph Kristeller, D.D.S., Reporter
On April 16, Dr. Julius Levy, Director of Child
Hygiene of the State Department of Health, was
the essayist of the evening at the Academy of
Medicine of Northern New Jersey. He cited the
reduction of infant mortality from 112 per 1000
in 1918 to 55 per 1000 in 1930, progress that was
due to the advancement of child hygiene, which
should not be confused with the medical care of
sick children, but is mainly educational and pre-
ventive in nature. A child hygiene bureau gives
prenatal advice to expectant mothers by nurses,
prenatal care and medical examination by physi-
cians in private practice and in clinics, and proper
obstetric care. The bureau further supervises in-
fant care through Baby-Keep- Well Stations, where
necessary. It advocates immunization of children
of pre-school age against smallpox and diphtheria
and advises proper diet to insure good teeth. Pre-
vention of blindness at birth, proper care for ille-
gitimate children and their mothers, and elimina-
tion of baby farms is also the aim of child hy-
giene.
The bureau cooperates with other social agencies,
and tries to improve sanitation and housing con-
ditions. It discovers and properly cares for crip-
ples and follows up cases of deformities. Two
forms of death rate have not decreased in the last
10 years. One is the infant mortality rate for
the first month of life, the other, maternal.
Dr. Levy concluded by saying that numerous
measures were still necessary to aid further de-
velopment of child hygiene, namely, the more ef-
fective control of respiratory disease, premature
births and cerebral hemorrhage.
Dr. Elmer G. Wherry said that Dr. Levy, with
the late Dr. Henry L. Coit, did much of the
pioneer work in child hygiene.
Dr. Rathgeber, in turn, honored Dr. Wherry as
pioneer also in that field.
Dr. Edward T. Wharton discussed dental as-
pects of child hygiene, particularly in relation to
the improvement of diet for greater calcium de-
posits and greater masculatory function.
GLOUCESTER COUNTY
Henry B. Diverty, M.D., Reporter
The regular monthly meeting of the Gloucester
County Medical Society was held May 21, at the
Woodbury Country Club. The speaker of the even-
ing was Dr. D. S. B. Pennock, of Philadelphia,
whose subject was “Has Manipulation a Place in
Medicine?”
The following were present: Drs. I. W. Knight,
C. I. Ulmer, R. K. Hollinshed, D. Campbell, H. B.
Diverty, O. R. Wood, W. J. Burkett. E. E. Downs,
B. A. Livengood, H. Nelson, H. M. Fooder, Church,
Ristine, J. H. Underwood, F. G. Wandell, Corson,
of Cumberland, and Kline, of Camden.
The members of the Woman’s Auxiliary to the
Gloucester County Medical Society were present at
the reading of the paper by Prof. Pennock.
A luncheon was served after the literary pro-
gram.
HUDSON COUNTY
Harry J. Perlberg, M.D., Secretary
The regular meeting of the Hudson County
Medical Society was called to order at 9.30 p. m.,
the president, J. M. Cassidy, in the chair. The
minutes of the previous meeting were accepted
as printed in the Bulletin.
The president reported the Executive Committee
meeting of April 27 at the Carteret Club.
Mr. Etiror), of the Druggists’ Association, spoke
regarding the tradesmarking and renaming of
well known U. S. P. preparations and formulas by
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
527
well known drug' houses, which are widely adver-
tised to the physicians for them to prescribe under
easily remembered names. The average intelli-
gent citizen now reads all of his prescriptions and
then re-prescribes for himself and his friends,
the druggist dispensing over the counter.
Mr. Feinbers, of the druggists’ committee, also
spoke, giving the druggists’ angle on this mat-
ter. There was considerable discussion.
Dr. Alexander moved that a committee of 3 be
appointed by the president to study and offer
concise suggestions regarding the matter, and to
confer with a similar committee to be appointed
by the Druggists’ Association. Carried.
Dr. Shapiro spoke regarding preschool examin-
ations and said he was ready to cooperate with the
society in determining the proper attitude toward
them and the manner in which they should be
handled. He said that the County Medical So-
ciety recognized the value of preschool examin-
ations but deemed it wise to refer such examina-
tions to family physicians to prevent the over-
burdening of school examination facilities.
Dr. Maras made suggestions regarding the pro-
gram for the May meeting, and also spoke ex-
tensively on the matter of public relations.
Dr. Waters moved that a sum, not more than
$500, be appropriated to the Welfare Committee
for use in advertising for the benefit of the Hud-
son County Medical Society.
A conference had been held with the Committee
of Druggists in reference to the prescribing of
various compounds by physicians. The following
resolution had been presented by the Druggists’
Association :
Whereas it is becoming a rapidly growing prac-
tice among pharmaceutic manufacturers to com-
pound various well known formulas' and introduce
them to the medical profession under proprietary
names, and
Whereas such preparations contain ingredients
of known and definite standards and which are
commonly found on all drug store shelves, and
Whereas the pharmacist is capable of making
these compounds without any difficulty, and
Whereas the introduction of these compounds
under proprietary titles and in easily identified
packages, design or colors, increases the tendency
to self-medication, since usually these proprietary
names are of such character as to be perfectly
legible to the lay public, and
Whereas the recommendation of these com-
pounds through prescribing by the medical pro-
fession is accepted by the public as an unqualified
endorsement for the preparation, and
Whereas the cost of these compounds are neces-
sarily far in excess of normal, due to the fact
that advertising, detailing and distributing costs
must be absorbed, and thus necessarily bring the
cost to the patient far in excess of the actual
value of the preparation as compared with the
cost of the same preparations when compounded
by a pharmacist,
Be It Therefore Resolved that the Hudson
County Retail Druggists’ Association, in the in-
terest of a closer cooperation with the physician,
pharmacist and patient, deprecates the practice of
prescribing, recommending and fostering the use
of such compounds under a proprietary title.
The following resolution was presented regard-
ing preschool examinations:
Preamble. The large number of children enter-
ing the schools each year who have demonstrable
physical defects, evidences the need of having all
children of preschool age carefully examined, and
sufficiently in advance of their entrance to school
so that correctable defects may be treated and
the child put in the best physical condition to get
the most from his schooling with the least dam-
age to his health. Dr. Haven Emerson recently,
in an address before the American College of
Physicians, stated that 65% of all children enter-
ing school show some physical defect.
The resultant loss of time and delayed educa-
tional progress caused by illness due to neglect to
correct physical defects amenable to treatment, is
unfair to the child, and a great economic waste.
Also the school days lost, to correct defects after
entrance to school, which could have been treated
a few months earlier with added advantage to
the child, is an indefensible waste of valuable time.
We believe the physician who has treated the
child for the usual illnesses of early childhood is
best qualified to make this complete examination
and to advise treatment for defects found.
We are desirous of cooperating with the school
authorities, medical directors and inspectors of
the schools of the county, in every reasonable way,
in an endeavor to improve this situation. We
feel, however, that it is not the function of school
systems, through their medical inspectors, to ex-
amine children who are not actually attending
school, therefore,
Resolved that the Hudson County Medical So-
ciety recognizes the need for an increased inter-
est and understanding on the part of parents, of
the value of examination of children of preschool
age, and wishes to cooperate with the various
school authorities and established health agencies
of the county in bringing to the attention of the
public the necessity for these examinations. But,
believing, for the reasons above set forth, that
the examination of the child should be cared for
by existing agencies, i.e., private physicians . and,
in the case of those unable to pay, established
clinics; and also convinced that it is not the legiti-
mate function of the schools to engage in this
medical activity, other than for proper publicity to
show its need and value, therefore be it further
Resolved that no members of this society, in
their capacity as medical directors or inspectors
of the school systems of the county, shall engage
in the examination of children until they are ac-
tually attendants of school, and be it further
Resolved that the several Boards of Education
of the county, and all members of this society,
be apprised by letter, of the action of the society
relative to this matter.
It was regularly moved and seconded that this
be adopted and the motion was carried.
The Board of Censors reported favorably upon
the following applicants: Nicholas M. Alter, and
Lawrence V. Lindroth.
Post-Graduate Committee, Dr. L. C. Lange,
chairman, reported that 36 members had signed up
for the course.
Publicity Committee, consisting of Drs. Maras,
Jaffin and Schwarz, rendered the following report:
(1) To bring before the public any subject per-
taining to Medical Science and the Practice of
Medicine.
(2) A program of education of the public with
the sole purpose of enlightening the public on the
results of scientific efforts in the prevention, con-
trol and cure of disease.
(3) A program to enlighten the public on the
source of knowledge of medical science and upon
the methods by which this knowledge is acquired.
(4) Radio broadcasting by authorities in the
various branches allied to medical science: Dr.
Salmon, Chief of the Division of Health of Jersey
528
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1031
City; Dr. Brinkerhoff, Chief Medical Director of
the Public Schools,
(5) Lectures before the Chamber of Commerce,
Service Clubs and other organizations of the laity.
Lectures on medical topics by members of this
society are offered to any organization or bodies
of laity, other than the Civil Courts, which de-
sire them, for the purpose of learning or for ex-
pert medical opinion, not involved in the Civil
Courts or other Bureaus of Litigation. Such lec-
tures and expert opinions to be first submitted to
the Executive Board, for censorship, before they
are rendered to the ones seeking' same.
(G) Lectures in Public Schools, Parochial Schools
and High Schools on medical topics such as “Im-
munization against Diphtheria, etc. We recommend
to the authorities that such lectures be presented
by the Medical Inspectors in their respective
schools.
(7) Showing of moving pictures on diphtheria,
in the High Schools.
(8) Distribution of pamphlets to school chil-
dren, on diphtheria prevention.
(9) Distribution of posters in windows of busi-
ness stores and other places, of protection against
diphtheria.
(10) Printing and distributing to members dis-
play cards “Endorsing Immunization Against
Diphtheria”. Also printing and distributing
record sheets, to be filed by the Local Board of
Health of each community for permanent record.
(11) Printing of Publicity Committee station-
ery.
(12) Conducting campaign of immunization
against diphtheria, through the public press, news
columns and paid advertising, “to make the pub-
lic diphtheria minded”.
(13) Meetings were held at numerous instances,
by this committee, together with President Cas-
sidy, to formulate a basis for future working plans
in the great field open to the medical profession
in this country, whereby a free practice of medi-
cine may be obtained, unhampered by legislation
propounded and foisted upon the profession by
lay organization.
(14) Communications were sent out to various
societies, including the New York Academy of
Medicine, the Academy of Medicine of Northern
New Jersey and the American Medical Associa-
tion, informing them of our intentions and re-
questing their own experiences and ideas on the
matter.
At this time it is the extreme pleasure to report
a communication from the Hon. Frank Hague,
Mayor of Jersey City, through his office and medi-
cal staff, on the campaign against diphtheria, with
which he is heartily in accord. He also delegated
Dr. Salmon, Chief of the Flealth Division, to repre-
sent the interest of Jersey City in this campaign
and suggested obtaining all the publicity possible
for this campaign, and he will approve whatever
is decided upon in the course of this program.
(16) Joint meeting held of the Publicity Com-
mittee and the Boards of Health of Hudson
County.
Discussion of health measures advocated in our
State Legislature, activities of various groups at-
tempting to gain control of and “harness medical
profession”. Campaign against diphtheria, a
health measure threatening us and forced upon
us, and by execution of which we will prevent
lay organizations from gaining access to the medi-
cal profession and meddling with its affairs.
The statistics on diphtheria having been investi-
gated by Dr. Schwarz, of the Publicity Committee,
who will represent same at May meeting of
this society, it is shown that the percentage
of positive Schick tests before immunization of
the large numbers during such campaigns is so
small that it does not warrant its execution at
such times: and New York City, as well as other
large communities of the country, has deferred
Schick testing to a period 4 to 6 months after in-
oculation. It was also shown that toxin-antitoxin
is preferred to toxoid.
(17) Attended meeting of Executive Board and
discussed abuses by Medical Inspectors of Public
Schools in their examination of preschool children
in the Public Schools of Union City, without due
compensation, thereby initiating the first step of
“state medicine”.
Publicity Committee was instructed by the
Executive Board to conduct the campaign against
diphtheria at its own discretion and authorized the
Publicity Committee to call upon the members of
this society for assistance in writing articles for
the public pres>s, and same to be entered as
“sponsored by the Hudson County Medical So-
ciety”.
The Schick test to be stressed at the time of
inoculation and arrangements made by physicians
to make such test 6 months after inoculation.
Advertise the campaign in the public press.
Report May meeting of the Hudson County
Medical Society to the press, instead of inviting
members of the press to attend that meeting.
Publish the list of members of the Hudson County
Medical Society in the public press.
Appropriation of $500 was made to be used by
the Publicity Committee in its present activities.
(18) On April 29 attended the Councilor Dis-
trict Meeting at Hackensack. For delegates to the
State Convention, from Hudson. Passaic, Sussex
and Bergen Counties.
(19) Held Joint Meeting of the Boards of
Health of the various commuties of Hudson
County and the Publicity Committee, to make final
arrangements for the campaign of immunization
against diphtheria.
There has been no representative nor communi-
cation received in answer to (requests to join this
campaign from the following communities: West
New lrork, East Newark, Harrison, Secaucus and
Guttenberg.
The campaign is being conducted in Union City,
which is partly administering to 7 communities:
Weehawken. Kearny, North Bergen, Hoboken.
Bayonne campaign is postponed to May 12, after
election.
The following letter from Mayor Hague to the
Publicity Committee was read: “The campaign to
immunize against diphtheria which your society
is about to inaugurate in Hudson County, and par-
ticularly in Jersey City, has my hearty approval and
endorsement. A similar campaign carried on by
our health department about 2 years ago achieved
very satisfactory results, although it was the first
one attempted here and it is only fair to suppose
that with your carefully organized program and
the experience we had in the former campaign,
that your efforts will be more completely effective,
and productive of more complete and informing
results.
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
529
Every city department concerned will g-ladlv co-
operate with your body in making the movement
successful. The Health Bureau will furnish the
necessary serum free to physicians, and the Board
of Education will aid you in any reasonable way
in the school part of the work. The city physi-
cians and nurses in the public and parochial school
will also do their part cheerfully.
Wishing you every success in the campaign, I
am,
Very truly yours,
Frank Hague, Mayor.
The following nominations were made from the
floor for members of the Nominating Committee
to serve in 1932, and all were elected: Drs. Poliak,
Cosgrove, Klaus, Maras, Chapman, Alexander, M.
Shapiro, B. T. D. Schwarz, Binder and Jaffin.
Dr. B. Maras nominated Dr. B. T. D. Schwarz
and Dr. Leonard Fauqier as members of the Pub-
lication Committee, and they were duly elected.
Drs. Nicholas M. Alter, 85 Van Reypen Street,
Jersey City, and Lawrence V. Lindroth, 4633 Hud-
son Boulevard, North Bergen, were declared elect-
ed to membership.
The president announced that there would be
a meeting of Delegates and Alternates to the State
Society on Monday, May 25, at 9 p. m., at the
Carteret Club.
Dr. J. B. Morrison, the State Society Secretary,
made a few brief remarks. He stated, among
other things, that the Welfare Committee of the
State Society had been extremely energetic; that
no Bill inimical to the profession had passed the
legislature this year. He spoke in reference to
the Post-Graduate Courses and stated that he
expected next year to have money appropriated
so that the courses would be given all over the
state for a nominal fee of $10.
In reference to the bill concerning the discus-
sion of specialties, he felt that this matter should
be kept out of politics and within the State So-
ciety, that they should be empowered to certify
to the qualifications of various specialists.
He advised the Publicity Committee to get in
touch with the Parent-Teacher Associations and
get a list of children who are going to enter
schools. He asked that the report of the publicity
committee submitted at this time be sent to him
and a condensed report to the secretary of each
county society.
The president appointed the following committee
to confer with druggists: Drs. Alexander, Chair-
man; J. Koppel, and S. G. Scott.
Dr. Joseph Schapiro moved that a committee
be appointed to confer with the Medical Directors
of schools of the various municipalities of Hud-
son County, so that some concrete action could
be formulated in accordance with the resolution
adopted at this meeting.
The secretary moved that he be authorized to
print and distribute the new constitutions to the
members of the county society; carried.
Dr. Alexander moved that the recommendation
of the Executive Committee appropriating $500
for the Publicity Commmittee be approved by the
society. The motion was seconded and carried.
The president asked that every man keep a
record of the children he immunizes so that the
names can be sent to the Chairman of the Pub-
licity Committee, or the county society secretary.
Papers of the Evening
Dr. A. E Jaffin read a paper on “The Role of
the Practicing Physician in Public Health Af-
fairs’’. As good citizens and by virtue of pro-
fessional training, we are especially qualified to
give advice in public health affairs. It' is the duty
of every physician to thoroughly enlighten the
public regarding false cures, quacks, cults, etc.
The public interest should be stimulated in good
medicine as it always has been in travel, history,
music or other sciencies. They should be made
familiar with the methods of prevention of con-
tagious diseases so that in civil life typhoid and
small-pox can be eliminated as thoroughly as has
been done in the army. The same, of course, now
holds true of diphtheria.
With regard to the periodic health examination,
while it may not be wise to stress it too much, for
fear of criticism directed toward the financial ad-
vantage of the same to the physician, nevertheless
the importance and value of such examinations
should always be emphasized and the plan en-
couraged by every physician. Too often the doc-
tor is disinclined to make this examination just
because the applicant does not happen to be ill.
The early diagnosis of tuberculosis may prop-
erly be considered in this connection. The physi-
cian’s duty is not ended with the diagnosis of an
individual case until all the other individuals ex-
posed to this patient have also been properly and
carefully checked. It is much to be regretted
that many physicians, after making the diagnosis
of tuberculosis, still send the patient off on his
own to lead an undisciplined life for a longer or
shorter time, permitting the patient to lose the
benefit of proper methods of curing.
The practice of teaching rational living rather
than seeking remedies for the effects of irrational
living cannot be too strongly emphasized. Every
doctor would then make of himself a health officer
in private as well as in public practice. He will at
the same time help maintain the fundamental in-
timate relationship that should exist between doc-
tor and patient. A faithful adherence to these
duties will, more than anything else, eliminate the
gradually increasing economic problem facing the
general practitioner.
Altogether these efforts will constitute good
medicine, good practice, and good public service.
Other papers presented were: Symposium —
“Tuberculosis in Children”: (1) “History, Symp-
toms, Pathology” by Dr. Walter Gonzales, Ho-
boken. (2) “X-ray Diagnosis and Interpretation”,
by Dr. Benjamin Joseph. (3) “Tuberculin-Reac-
tion; Technic and Interpretation”, by Dr. Harold
Tidwell. (4) “Treatment and Prognosis”, by Dr.
Edward Lupin.
Short History of Diphtheria Eradication
Berthold T. D. Schwarz, M. D.,
Member Publicity Committee Hudson County
Medical Society, Jersey City
Diphtheria, . the scourge of childhood, is fast dis-
appearing. Near the close of the last century,
there were more than 150 deaths from diphtheria
per 100,000 population. In 1930 the rate has drop-
ped to less than 4 per 100,000, truly a remarkable
reflection on the efforts of preventive medicine.
The death rate from diphtheria in the nation, in
the brief space of 3 years, has been practically cut
in half. The death rate has been reduced more
030
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
than 1/3 in 1930 over that of 1929. Since 1911 it
has diminished more than 80%.
Diphtheria is a very old disease. Writings of it
can be found in the Babylonian Talmud. Aretaeus
described the disease in the first century. Diph-
theria swept over the civilized world, in the form
of great throat pestilences in the middle ages,
particularly in Spain, and continues throughout all
countries to the present day.
While diphtheria usually attacks those under 6
years of age, it has also caused death to men
famous in world history. Diphtheria caused the death
of George Washington. It is highly infective
and is transmitted from one person to another.
The boy King of Roumania is reported as having
the disease and his mother, Princess Helene, is
reported to have contracted the disease while
nursing her royal son.
Until the cause of diphtheria was discovered by
Klebs, in 1883-, and isolated 1 year later by Loef-
fler, the medical profession was very seriously
handicapped in fighting this deadly disease. Ig-
norance is deadly. The early attempts to control
diphtheria were directed toward the isolation of
those affected by the disease and disease carriers.
Because of its marked prevalence in those days,
it was rather heart-breaking on the part of Boards
of Health in the last century to cope with this
problem of diphtheria prevention. Cultures were
taken of the nose and throat of suspected indi-
viduals but since there were also many individuals
who were not sick, yet carried the germ and in-
cidentally transmitted it to others who were sus-
ceptible, the efforts directed toward its control
seemed to be all in vain. It was apparent that in
order to successfully control the disease at that
time, it would be necessary to isolate almost the
entire population; an impractical solution.
Fortunately, not long after, the toxin evolved
by the diphtheria germ was discovered, especially
by the works of Roux and Yersin. The dis-
covery of the poisonous element of this disease led
to further research. Von Behring found the means
by which the poisonous substance could be neu-
tralized. This serum was called “antitoxin”. How
efficacious diphtheria antitoxin is in the treatment
of diphtheria, and the immunization of those al-
ready exposed to the disease, is graphically indi-
cated in the remarkable decline of about 82% in
the death rate. It does not take much to visualize
the very great saving in lives, or the amount of
anguish and financial loss, which illness or death
causes. The use of antitoxin has resulted in the
saving of about 10,000 lives each year! Little won-
der that infant and childhood mortality has di-
minished.
Although many would say that the advance of
diphtheria prevention has reached its highest peak
with the use of antitoxin, it is characteristic of
men of science to ever probe deeper for more ef-
fective control of disease. The incidence of diph-
theria, despite antitoxin, was still too great. Well
over 15,000 children still died of this disease yearly
in the United States. To alert minds it demon-
strated the fact that a surer preventive must be
found before this dreadful disease could be con-
quered.
The serum which specifically combats the poison
of diphtheria is mostly obtained from horses, which
are inoculated with the diphtheria toxin. When
toxin is administered in sublethal amounts it
evokes a reaction on the part of the horse to
neutralize it. So provident is nature in elaborat-
ing a defense that its neutralization efforts result
in a considerable excess of antitoxin which may
be separated from the horse serum and purified for
use in treating diphtheria. It was found that when
mixtures of diphtheria toxin with antitoxin were
administered, the horse did not become as sick, and
still produced a very fine antitoxin. Dr. Theobald
Smith suggested that this method of mild reaction,
using diphtheria toxin-antitoxin in horses, be used
in immunizing human beings against diphtheria.
Dr. Schick, in 1913, found that by injecting a
very minute amount of the toxin-antitoxin into
a superficial layer of the skin it could be deter-
mined whether or not the person tested was im-
mune or susceptible to diphtheria. It was sub-
sequently found that individuals of different ages
had a varying susceptibility to diphtheria. Dr.
Park and his associates in testing thousands of
individuals with the Schick Test determined that
the susceptibility at different ages ranged as fol-
lows:
Agf. Susceptibility
LTnder 3 months 15%
3 months to 6 months 30%
6 months to 1 year 50%
1 year to 2 years 00%
2 years to 3 years 60%
3 years to 5 years 60%
5 years to 10 years 30%
10 years to 20' years 20%
Over 20 years .. 15%
It is easily seen that the largest incidence of
the disease and death occurs between the ages of
3 and 5 years, the preschool age.
Diphtheria can be successfully controlled only
by the administration of toxin-antitoxin or toxoid
because individuals transmit the infection to
others frequently without realizing that they are
subjects of diphtheria. It may manifest itself
merely as a slight nasal catarrh, mild tonsillitis, or
running ear, or it may be transmitted by diph-
theria bacillus carriers. Long after recovery from
diphtheria the germs may linger in the throat.
As a rule, a person is considered free from diph-
theria if he shows 4 successive negative throat
cultures. Most cases are not infectious after a period
of about 5 weeks. In some, however, the infection
exists for several months. The diphtheria toxin
cripples the heart and damages the nervous sys-
tem. Antitoxin neutralizes the toxin and prevents
damage. Besides being curative, when used, it
gives a temporary immunity of about 6 weeks’
duration. This immunity conferred by antitoxin is
called passive. When toxin-antitoxin is given it
creates an active .immunity; that is, the individual
elaborates his own antitoxin. So far as is known,
the duration of this active immunity is lifetime.
Diphtheria immunization by toxin-antitoxin be-
gan to be employed on a large scale after 1920. In
1920 over 15,000 school children died of diphtheria!
In 1930, thanks to the effects of toxin-antitoxin
administration, the number of children in the
United States who died is well below 5000.
Since this is the occasion of inauguration of a
“diphtheria eradication campaign”, conducted by
the Hudson County Medical Society, we can scan
with interest the United States Public Health
Service reports for the year 1929, the last avail-
able year, which shows the incidence of diphtheria
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
531
in the various communities of Hudson County, to
be as follows: Jersey City, 537 cases; Bayonne,
168; Harrison, 18: Hoboken, 57; Kearny, 10;
Union City, 51; West New York, 43. Data for the
other communities is not available at this time,
but it is certain that the reported incidence of
diphtheria in Hudson County for the year 1929
indicated well over 1000 cases. The entire state of
New Jersey reported 5361 cases. The death rate
of diphtheria in Hudson County was approxi-
mately 10% of the cases reported. The presence
of diphtheria in any community is an insult to
the intelligence of that community.
While there are numerous cities that have amply
demonstrated the efficacy of diphtheria cam-
paigns in the past, it may suffice to know the
findings of an investigation conducted by the
Metropolitan Life Insurance Company, which
found that during the years 1926 to 1929, where
campaigns were instituted against diphtheria in 53
cities, the diphtheria mortality diminished 33%.
In 31 cities where no campaigns were made, there
was a 9% increase in diphtheria. A classic ex-
ample of what diphtheria immunization can do is
illustrated in the town of Auburn, N. Y. In the
year 1922, toxin-antitoxin was administered to 58%
of the school children and in that year no case of
authentic diphtheria developed in that group.
Among the 42% that were not immunized, there
were 80 cases of diphtheria reported and 13 deaths
occurred. In 1923, 73% of the school children were
immunized, and no authentic cases of diphtheria
were reported, while among the 27% not im-
munized there were 15 cases of diphtheria reported
and 1 death. In 1924, 85% of the school popula-
tion was immunized and among these children, no
■case of diphtheria occurred; among the 15% not
yet immunized, there occurred 3 cases among the
■school children and 3 cases in the preschool age.
In the year 1925 no case of diphtheria was re-
ported. In the years prior to immunization there
was an average of 104 cases of diphtheria and 14
deaths occurring therefrom, reported yearly. This
is also the story of San Joaquin, California, and
Grand Rapids, Michigan, and other cities. For
every day of the year 1930 there were 22 people
who died from diphtheria.
Surely with means at disposal of the medical
profession, and with the aid of an aroused, in-
telligent public, diphtheria can be vanquished.
Clinical Society of North Hudson Hospital
J. Africano, M.D., Reporter
The regular monthly meeting of the Clinical So-
ciety was held Tuesday, May 12, with Dr. B. Koop-
erman acting as Chairman, and 55 members and
guests present.
Dr. Tannert read the hospital report for April:
224 admissions, 227 discharges; 20 deaths, of which
7 were medical, 6 surgical and 4 new-born.
Dr. W. Braunstein briefly discussed the 7 au-
topsies (35% of the deaths) performed during the
month.
Case Reports
Dr. E. Bailyn. “Empyema and Generalized Tuber-
culosis in Infant of 7 Months.” J. P., white in-
fant, 7 months old, admitted on February 20, with
history of chronic productive cough, dyspnea,
cyanosis and generalized eczematous rash over
face and body. No evidence of tuberculosis in
family. The infant was a full-term baby, normal
delivery and bottle-fed, developing normally until
4 months old, when a cough started and gradually
became productive and spasmodic in character; so
severe at times as to cause cyanosis. There was no
history of convulsions or vomiting and no fever was
observed. In that same period a scaly rash 1 appear-
ed about the head and face; also a mass in the
upper right femoral region. Examination of chest
revealed decreased expansion of the left side, which
was flat on percussion, with markedly diminished
voice and breath sounds. Abdomen negative. In
the right femoral region a large gland, the size
of a walnut, could be felt. Diagnosis of left-sided
empyema was verified by a roentgenogram. Thor-
acotomy was done and about 4 oz. purulent material
was evacuated, which on culture proved to be
full of pneumococci. There followed a very stormy,
postoperative course. In spite of good drainage,
there were remissions and exacerbations and prac-
tically no improvement in the spasmodic cough,
which now became very brassy and could be
heard all over the ward. The temperature be-
came septic in type and the child expired on
March 12'.
Autopsy findings: (1) A cluster of very much
enlarged nodes, partially overlapping and sur-
rounding the pericardium, trachea and bronchi,
which on section presented areas of caseation. (2)
The pleural cavity contained a moderate amount
of fibrinopurulent exudate, and lungs were diffusely
infiltrated with small whitish nodules. (3) Ab-
domen contained no excess of fluid. Liver was of
normal size, but greatly congested, and spleen
had a few scattered, minute, whitish spots sug-
gestive of tuberculosis.
The important points in this case are (1) its
comparative rareness in children under 1 yr. old;
(2) the complication of empyema following the
original pneumonia which activated the latent t.b.
focus in the glands; (3) the characteristic chronic
cough which sounded very much like a whooping-
cough of 3 months’ duration, and corfld be ex-
plained as a stridor caused by pressure of the en-
larged tracheobronchial glands; (4) the extremely
poor prognosis in generalized tuberculosis in young
infants.
Dr. Stein. “Meningococcus Meningitis Treated by
Cisternal Puncture.” M. S„ white, male infant, aged
5 V2 months, admitted on April 16, with history of
vomiting, fever and anorexia for 2 days. Anterior
fontanelle bulging; eyes staring; pupils equal and
reacting normally; neck showed marked rigidity;
knee-jerks exaggerated; Babinski positive; Ker-
nig’s sign present; temp. 103°; pulse 156, respira-
tions 28. Spinal tap yielded about 7 c.c. turbid
fluid under slight pressure. Cell count 21,300.
Smear and culture positive for meningococci. Blood
count: R. B. C., 3,284,000; Hb., 65%; W. B. C„
8100: polys, 42%.
On April 17, spinal tap yielded only 1 c.c. turbid
fluid, but cisternal puncture brought 25 c.c. turbid
fluid under high pressure. During the following
3 weeks cisternal puncture was performed about
20 times; on 7 occasions, antimeningococcic serum
was given by the cisternal route. After the first
week there was definite improvement, but then
the child had projectile vomiting, became stupor-
ous, finally comatose, and died on May 12.
The spinal canal was blocked practically through-
out the entire course of the disease; at times dur-
ing the later stages of the disease there was also
blocking of the cistern. There was no very mark-
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1031
532
ed benefit that could be attributed to the serum.
Apparently, there was much more relief obtained
by drainage through cisternal puncture.
The pathology in this case was probably exten-
sive, involving the base of the brain. Judging from
the block in the spinal canal and the xantho-
chromic nature of the cerebrospinal fluid, there
was hemorrhage and an extensive plastic exudate
involving the base of the brain and spinal canal.
Probably there was no block in the ventricles, be-
cause the bulging fontanelle would always become
soft after cisternal drainage. The pathologic state
of the subarachnoid space at the base of the brain
prevented absorption of the cerebrospinal fluid and
caused increased intracranial pressure, as was
evident by the bulging tense fontanelle which had
to be relieved by frequent cisternal puncture.
Dr. Luippold. “Hypertrophic Cirrhosis of the
Liver.” The following 2 cases occurring in our
wards in rapid sequence will serve to illustrate
how difficult it is at times to make diagnosis of
liver disease. A R., male, aged 67. was admitted
March 3, complaining of weakness, fatigue, short-
ness of breath and nervousness. Previous history:
typhoid at 27; “rheumatism” 10 yr. ago; drank
beer moderately for many years, occasionally a
little whiskey. About 1 month ago had, according
to his description, a definite attack of grippe.
Since then, he had felt weak, with a decided
dyspnea upon exertion; so much that it was diffi-
cult to climb even a flight of stairs. He also
noticed a marked nervousness, and at times a
marked tremor all over the body. Excessive
sweating upon the slightest mental or physical
strain was another feature.
Physical examination: Well developed and well
nourished, with sallow complexion, and depressed,
anxious facies; coarse tremors of both hands;
sclera slightly icteric; tongue coated, also with
coarse tremor; teeth in poor condition; heart
sounds weak but of regular rhythm, with sys-
tolic murmus at apex. The liver margin was palp-
able below level of umbilicus and could be made
out extending away over and under left costal
margin, with a smooth surface throughout, only
slight tenderness upon deep palpation, and no
pulsations perceptible. The spleen appeared mod-
erately enlarged. No evidence of ascites, nor
edema of extremities; abdomen moderately tym-
panitic.
Blood count showed a mild secondary anemia.
Wassermann and blood chemistry negative.
Icteric indices from 34-50. Stool on gross ap-
pearance fairly normal, but biochemically strongly
positive for blood. Van den Bergh test gave im-
mediate direct reaction. Urinalyses negative.
About March 19 the presence of fluid in the ab-
domen became evident, and an icteric tint to the
skin and conjunctiva more apparent. Patient more
somnolent. Paracentesis abdominalis was per-
formed March 29, when only a few ounces of fluid
were obtainable, but oh April 4, 52 oz. were re-
moved. After this he seemed a bit better for a
day or two, but then gradually lapsed into an
irrational, stuporous, involuntary state and finally
into coma; coincident with this he developed a
hypostatic pneumonia and died April 12.
While at first liver congestion secondary to a
heart lesion was suspected, it soon became ap-
parent, especially after the ascites developed, that
the condition was more probably a portal cir-
rhosis, but a diagnosis of malignancy could never
be entirely ruled out.
Autopsy revealed an enormously enlarged liver
occupying the greater part of the abdominal cavity;
weight estimated at 10 lb. There were very strong
bands of surrounding adhesions. The organ was
brownish-green in color and uniformly granular,
with smooth surface, firm consistency and cutting
with resistance. Section showed a diffuse fibrosis
with bands of connective tissue running through
and about the bile-ducts, and polygonal cells dis-
torted and degenerated, i.e., as in a typical portal
cirrhosis. The lungs showed a congestive and
terminal pneumonia; the aorta an atheroma;
spleen was moderately enlarged from congestion
and fibrosis; and the kidneys showed parenchy-
matous degeneration.
C. L., male, aged 75, entered the hospital April
10, complaining of chills, fever and a jaundice for
the past 2 or 3 weeks, with dizziness, anorexia,
vomiting and constipation. Typhoid at 25; mod-
erate beer drinker throughout his entire adult life.
Apparently in continuous good health until 3
weeks ago when, while at work as a watchman,
he was suddenly seized with chills and fever. The
fever continued but at times seemed more pro-
nounced, and the chills also recurred at irregular
intervals. During the first 2 days had marked at-
tacks of vomiting. Jaundice was first noticeable
2 weeks ago and this gradually increased. Skin
and sclera markedly jaundiced. Drowsiness was
very pronounced, but he could be aroused with
little difficulty and gave evidence of an average
intellect and memory. Teeth very bad and tongue
heavily coated. Heart sounds regular; brady-
cardia; poor quality. Liver very much enlarged
and extended to 4 finger breadths below the costal
margin. Blood count: Hb., 69%; R. B. C., 3,550,-
000: W. B. C., 19,000: polys., 78%; lymphs, 22%;
coagulation 1-3% min. Urine showed small amount
of indican, much bile and urobilogen in dilutions to
1:200; feces chalky and negative for blood.
The somnolence became steadily deeper and the
jaundice more intense. The fever which had
fluctuated from 100-103° from the third to the
ninth day, gradually subsided to normal as the
patient slid into practically a coma the last 3
days before he died on April 26.
Comments: The acute onset of symptoms made
the diagnosis of an acute hepatic infection prob-
able. The larger liver was believed to be a latent
cirrhosis, which, suddenly activated by this com-
plicating, acute infection, disturbed the hepatic
compensation and rapid degenerative changes set
in even before marked ascites or hemorrhages
could have occurred. The jaundice was believed
to have been of toxic origin and also obstructive,
by occluded, swollen biliary ducts. On the other
hand, the advanced age of the patient, the enlarged
liver that had even the suggestion of masses in its
contour (to some of us), and the jaundice, re-
membering that it has been repeatedly demon-
strated that the jaundice of rrtalignant disease may
be ushered in by an accompanying acute gastro-
intestinal upset, all made the diagnosis of malig-
nancy likely.
Autopsy disclosed a very large liver weighing
about 10 lb. Color was dark greenish-brown; sur-
face, smooth; cut surface, granular with exudation
of greenish material; bile-ducts, markedly dilated:
gall-bladder distended and filled with a watery
fluid (hydrops). Microscopic section of liver
showed a fibrosis about the bile-ducts, with edema
and dense collections of polys, thus featuring an
acute, suppurative cholangeitis with congestion,
and an early biliary cirrhosis, probably secondary.
Spleen was slightly enlarged and congested: the
kidneys were polycystic with amyloid degenera-
tion ; and the pancreas showed fibrosis and conges-
tion.
Dr. 8. Braunstein. “Perinephritic Abscess.” A
woman, aged 48, admitted April 5. with complaint
of pain in the left hypochondrium and weakness.
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
533
Typhoid at age of 2; hemorrhoidectomy at 16; all
teeth were extracted at age of 29. Has always
been constipated and troubled with gas. Had a
cough about 4 weeks ago lasting 10 days; no ex-
pectoration. Has lost 29 lb. No urinary symptoms.
Onset dates back to January, when she had
chills and fever; she believed grippe. Following
this, she developed an otitis media which ruptured
and discharged for several days. A few weeks
later she had a nonproductive cough lasting 10
days, so severe that it left her with a terrific pain
in the left abdomen; pain not controllable with
opiates.
On April 1 the patient was seen at home; she
showed evidence of marked weight loss but ex-
amination was negative except for the abdomen,
which was soft; no rigidity, but there was marked
tenderness in the left upper and lower quadrants
and a large mass could be felt, hard and extending
from the xiphoid process to the left anterior iliac
spine. Urine showed a trace of sugar and no
albumin. Medical consultation was held 2 days
later and it was decided that the mass was a large
spleen due to infection, splenomegally or throm-
bosis in the splenic vein.
In the hospital, blood showed: Hb., 68%;
R. B. C., 4,100,000; W. B. C., 12,000; polys., 80%;
lymphs., 20%. Urine: 0.5% sugar, acetone and dia-
cetic acid. Temperature ranging from 100-103°. The
patient then felt better, temperature dropped, and
the mass became smaller; but 11 days after admis-
sion the temperature rose again and she complain-
ed pf severe pain in the region of the left kidney.
Examination showed a large fluctuating mass in
region of the left kidney. Dr. Klaus examined
her on the next day and felt sure that we were
dealing with a perinephritic abscess. She was
operated upon that same afternoon and a large
quantity of foul smelling pus was evacuated
through an incision over the left kidney region.
Following operation, the temperature dropped;
she was free from pain and the mass in the left
abdomen began to disappear. She was discharged
May 2, and with a diabetic diet and liver extract
is making a rapid recovery.
Dr. Klaus believed this to have been a primary
perinephritic abscess, in contradistinction to one
secondary to renal infection ; he cautioned against
depending upon the urinary findings to assist in
making the diagnosis; tenderness is the best sign
of deep-seated infection, as shown by the follow-
ing case which is similar to the one presented: a
boy who suffered with a “cold”, and extreme
tenderness in one of the loins — no abscess could
be palpated, as it was walled-off — there were no
signs in the urine, yet on operation a profuse
amount of pus had formed around the kidney, and
the patient was cured.
Dr. Lange suggested use of x-rays to diagnose
spleen from kidney, after injection of the rectum
with air; also, the feel of the spleen is softer and
more pliable than the kidney.
Dr. Luippold called attention to the low white
and low poly counts; with such a large amount of
pus under pressure a higher count would have
been expected.
Dr. D’Acierno suggested cystoscopy, and the P.
S. P. test as an aid in arriving at diagnosis.
Dr. Pearlstein summarized the sequence of
events as: ear abscess; hematogenous infection;
renal (cortex) infection, which healed and broke
into the capsule; then generalized infection, which
accounted for the splenitis; finally, infection of the
perinephritic space.
Dr. Hekimian described the relations of a peri-
nephritic abscess: there are 2 layers of fascia en-
veloping the kidney, one adherent to the organ
and the other paranephritic, between which there
is a large amount of fat having its own inde-
pendent renal vessel; thus is explainable how a
carbuncle, or an otitis, tonsillitis, etc., will lead to
a perinephritic abscess without involvement of
the kidney itself; also via the lymphatics, this
abscess may be consequent to adnexal disease, or
to chronic recurrent appendix. In diagnosing by
means of x-rays one should look for deviation of
the border of the psoas muscle of the affected
side.
Dr. Bender. “Acute Osteomeylitis of Femur in
Infant.” R. R., aged 7 months, white, born in this
hospital, instrumental delivery. Patient was ad-
mitted March 23 with diagnosis of osteomyelitis
of the left femur. Breast fed for 2 months, then
bottle fed. Bronchitis at 2 months. Pertussis at
4, which was cured within a month under vaccine
therapy.
Present illness began March 4, with fever, vomit-
ing, constipation, cough and sweats. Signs of
consolidation over the right lower lobe, with dul-
ness, bronchial breathing and fine crepitant rales.
Next day the signs on the right side increased,
and the pneumonic process spread to the left lower-
lobe. The following day the process had involved
the greater part of both lungs. Temperature at on-
set 103°, ranged between 104-105° until March 8,
when it dropped within a period of 3 hr. to sub-
normal, and the infant collapsed. Rallied under
adrenalin and camphor stimulation.
After 2 days of normal temperature, it rose to
101° and examination showed rales over the entire
chest. The ears showed bilateral myringitis,
which on puncture discharged profusely. March
18 it was noticed that the baby assumed a peculiar
attitude; left leg drawn up and slightly abducted.
On motion the child would cry pitifully. Radio-
gram of the hip confirmed the suspicion of os-
teomyelitis and showed destruction of the upper
part of the femur shaft. Chest picture at the same
time showed fibrosis and effusion in the lower right
chest and extensive pneumonia of the left lung.
Under regional anesthesia, an incision about 3 in.
long was made over the left trochanter; hip joint
exposed, opened and a large amount of thick pus
was aspirated; no loose or roughened bone. Owing
to the poor condition of the patient, no other pro-
cedure was taken and the wound was packed with
3 gauze drains and a rubber tube inserted. After
the operation the temperature began to rise rap-
idly and reached 107.6° at 7 p. m„ when the pa-
tient died. Exploratory puncture before the op-
eration failed to obtain any pus from the pleural
cavity. Culture of the pus from the femur re-
vealed the pneumococcus.
Dr. Klaus. “Jejunal Ulcer Following Pylorectomy
for Duodenal Ulcer.” G. D., male, aged 29, admit-
ted April 1 with a postoperative jejunal ulcer. One
year previously, he had been operated upon for a
large penetrating ulcer of the first portion of the
duodenum of 5 years’ duration. A pylorectomy was
done, which included both the ulcer and acid-
bearing area of the stom'ach ; the resection was
completed by a posterior Polya anastomosis; ap-
pendix also removed. The patient made an un-
eventful and rapid recovery and 2 weeks after
operation was discharged as cured. Upon dis-
charge he was entirely free of symptoms, but was
advised to remain on a special selected diet.
He was readmitted 6 months later with history
of having been perfectly well for months, when
he began to have cramp-like pains in the upper
abdomen, and particularly in the vicinity of the
old operative scar. At no time was there any
534
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
vomiting. The pains began shortly after eating
and continued for 1-2 hr. Gastric analysis showed
total acidity of 85; free HC1 40; combined 56; no
blood. X-ray examination showed nothing con-
clusive. A diagnosis of postoperative marginal
ulcer was made, and after 5 days of rest and diet
he requested to be discharged, feeling greatly im-
proved and practically free from abdominal pain.
He was back to the hospital in 5 months with
history that he had remained free of pain for 3
weeks after his last discharge but that the pains
returned much more severe, and have become
practically constant. Food has no relation to the
pain, nor does it relieve it; never any vomiting.
A diagnosis of marginal ulcer was made by the
Medical Service. The usual ulcer treatment was
thoroughly tried for 2 % weeks with no improve-
ment, and an exploratory laparotomy was done. A
large indurated ulcer 1x1% in. was found in the
jejunum on the spur between the 2 loops of
jejunum as they joined the anastomosis with the
stomach, the ulcer being situated directly opposite
the stoma. It seems fair to assume that the ulcer
formed at this point by the direct flow of gastric
contents pouring out into the jejunum. There was
much induration in the mesentery immediately
beneath the ulcer. The old anastomosis was taken
down, and the ulcer, together with about 5 in. of
jejunum and a portion of the stomach, were re-
sected. A new anastomosis was then constructed
by suturing the stomach to the distal loop of
jejunum by end-to-end suture and then suturing
the proximal, or short loop of the jejunum end-to-
side anastomosis to the jejunum below the new
stoma, this procedure constituting a Y-shaped
method on the Roux principle.
He was discharged again, free of any gastric
symptoms, about 2 % weeks after operation.
This case was presented because the complica-
tion of postoperative jejunal ulcer is frequently
seen following any operation for the cure of gas-
tric or duodenal ulcer. It is most commonly seen
following the simple gastro-enterostomy. Pylorec-
tomy, with excision of the acid-bearing area of
the stomach, has been in recent years especially
advocated to prevent just such a complication. Many
surgeons claim that jejunal ulcers will not occur
after this procedure, but that such is not the case
has been proved by numerous other such cases
in the literature.
I)r. Klaus. “Benign Pancreatic Tumor Compli-
cated by Subacute Pancreatitis.” G. S., female,
aged 26, married, admitted to the Surgical Service
April 3, with a sudden, severe abdominal pain of
24 hr. duration. The pain was intense and local-
ized to the epigastrium and right upper quadrant;
of a continuous character with radiation to the
back, as in gall-bladder disease. Vomiting had been
continuous since the onset and bowels had moved
effectually only with enemas. During the past 3
years patient had at least 5 similar attacks, but
of less severity. She was operated upon 2 V> years
previously for what appeared at that time a gall-
bladder disease, but she was told that a tumor was
found under the liver and that the gall-bladder
was not removed. She does not know what the
surgeon did at the time, but following the operation
she remained fairly well for several months. We
were unable to get any information from the hos-
pital where that operation had been done. Temp.,
on admission, 101°; pulse, 88; W. B. C., 17,800;
polys., 94%. Abdomen showed an old scar in the
right upper quadrant, slight distention, consider-
able tenderness and rigidity over the entire epi-
gastrium and right upper quadrant. No masses
could be felt. The urine showed a slight amount
of albumin and 0.2% sugar, which is of much
significance in light of the operative findings later.
From the history and physical findings a diag-
nosis of acute cholecystitis was made, and partial
intestinal obstruction was seriously considered, as
well as a perforated duodenal ulcer, yet there was
sufficient evidence to rule both these out. Acute
pancreatitis was not considered.
A considerable amount of slightly blood-stained
fluid was found throughout the abdominal cavity;
entire upper abdomen was a mass of extensive ad-
hesions to the old scar and the loops of intestines;
gall-bladder was completely obscured by the ad-
herent bowel; stomach likewise adherent to sur-
rounding viscera. After separating all these ad-
hesions, the gall-bladder was found slightly
thickened but otherwise normal; it contained no
stones; fat necrosis of the omentum in the upper
abdomen was noted. After separation of the ex-
tensive adhesions, it was found that at the pre-
vious operation an anterior gastro-enterostomy had
been done. After further investigation, a large,
hard, nodular mass, the size of an orange, was
found in the region of the head of the pancreas.
It is fair to assume from the history that this
tumor was found at the first operation 2% yrs.
ago, but why the gastro-enterostomy was done is
hard to explain unless it was thought that the
tumor was causing an obstruction to the stomach,
cr possibly might do so later. The long duration
of the pathology certainly excluded any malignancy
and it seems reasonable to assume that one is
dealing here with a benign tumor of the pancreas
that has not grown rapidly, or more likely a
chronic pancreatitis with a superimposed acute
attack of pancreatitis as definitely shown by the
blood-stained abdominal fluid, fat necrosis, and the
symptoms of severe abdominal pain, vomiting,
temperature and leukocytosis. Her past attacks
of abdominal pain were no doubt due to attacks
of pancreatitis.
The urine before operation showed sugar and
this continued for 1 week following operation and
then cleared up without any special treatment,
which shows we were dealing with a pancreatic
disturbance and that should have been considered
more carefully before operation in localizing the
lesion to the pancreas.
A cholecystostomy was done for the puropse of
draining not only the biliary ducts and liver but
likewise the infectious process of the pancreas.
The patient has made an uneventful convalescence
and has been discharged free of any symptoms
and in excellent condition after 4 weeks of drain-
age.
The case is presented as a most unusual one of
subacute pancreatitis in the presence of a large
mass in the pancreas which is either a benign
tumor or a chronic pancreatitis, in which the dif-
ferentiation at the time of operation could not be
made, but which most likely, from the history and
long duration, is a chronic infection of the pan-
creas.
MERCER COUNTY
A. Dunbar Hutchinson, M.D., Reporter
The Mercer County Medical Society met in the
Lecture Room of the Nurses’ Home, St. Francis
Hospital, May 13, with Dr. Swern presiding.
We had the inestimable privilege through the
efforts of our Treasurer, Dr. North, of hearing an
address by Dr. Chevalier Jackson, the premier on
bronchoscopy and esophagoscopy. A capacity
audience listened to Dr. Jackson while he described
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
535
in a most interesting manner “Bronchoscopic Ob-
servation on Diagnosis and Treatment in Suppura-
tive Diseases of the Lung”. Dr. Jackson illustrated
with lantern slides, chalk, and moving pictures
the many conditions arising within the pleural
cavity as the result of obstructed breathing, and
a rising vote of appreciation was tendered the
distinguished speaker.
Drs. Elmer J. Elias, J. L. Wikoff, A. J. Lattiere,
of Trenton, and J. C. Hiden,. of Princeton, were
elected Active Members; and Dr. Gerold H. Miller,
Cranbury, as an Associate Member. The applica-
tion of Dr. A. James Fessler was read and took
the usual course.
The President appointed Drs. Reddan, Douress
and Yaeger as a committee to draw resolutions on
the death of Dr. Walter Madden.
Committee appointed to consider the death of
Drs. (gray thorn, Seibert and Stratton submitted
resolutions which were read and adopted. (See
Obituary Section.)
A communication from the Trenton College Club,
with reference to the request of Dr. Joseph Colt
Bloodgood, of Johns Hopkins Medical School, for
opinions of certain statements to be presented to
the Board of Trustees of the American Society for
the Control of Cancer, was read and referred to
the Public Relations Committee.
A communication from Dr. James A. Fisher,
relative to the Golf Tournament, was read and due
notice taken thereof.
Dr. Sica, Chairman of the Committee on Con-
tract Practice, made a verbal report, with detailed
account of the various opinions, statistics and
schedules of fees received by the Committee as
the result of a questionnaire.
The motion carried that the next meeting of
the society will be held at the Hopewell Valley
Golf Club, in the afternoon of June 18.
MIDDLESEX COUNTY
Medical Section of Rutgers Club
John H. Rowland, M.D., Secretary
The medical group of New Brunswick was en-
tertained by Dr. F. C. Johnson, Chairman of the
Medical Section of the Rutgers Club, at a beef-
steak dinner at his home on the Easton Avenue
Turnpike, on Wednesday, May 13, at 7 p. m.
About 30 physicians were able to attend. It was
expected to hold the dinner at Dr. Johnson’s
mountain lodge at Dock Watch Hollow, but be-
cause of inclement weather a change was neces-
sary.
Before dinner. Dr. Johnson very appropriately
and with very sympathetic and touching attitude,
spoke of the recent deaths of Dr. Gruessner and
Dr. Schureman, speaking of their wonderful at-
tributes and the great loss to the profession.
After 3-4 hours of complete relaxation, and with
a satisfied gastro-intestinal feeling, the members
adjourned to their homes, having spent a very
pleasant and enjoyable evening.
MONMOUTH COUNTY
W. Von Oehsen, Reporter
The regular meeting of the Monmouth County
Medical Society was held Wednesday evening,
April 29, at the Berkeley-Carteret Hotel, Asbury
Park, Dr. William K. Campbell presiding.
Minutes of the previous meeting were read and
accepted.
Dr. J. Bennett Morrison. State Society Secre-
tary, addressed the meeting on some phases of state
medicine, acquainting the society with the workings
of certain arrangements which approach state
medicine in various sections of the world.
Dr. Henry O. Reik, Executive Secretary and
Editor of the Journal of the Medical Society of
New Jersey, spoke on the progress the Journal
had made during the past year.
Dr. Harvey S. Brown brought to the attention
of the society a letter which he had received from
the Board of Governors of the Monmouth County
Welfare Home. There was first a discrepancy in
the length of Dr. Brown’s service, and second, the
fee basis was against the minimum fee schedule
of the county society. It was moved by Dr. Stan-
ley Nichols, seconded and carried, that the Presi-
dent appoint a committee to meet with the Board
of Governors to arrange a satisfactory solution
to this problem. Dr. Campbell appointed Drs.
Harvey Brown, Fairbanks, Kazmann and Nichols.
Dr. James Ackerman reported for the Com-
mittee on Radio Broadcasting. It was brought up
that heretofore the names of the doctors have not
been used in the weekly broadcast and it was
decided that hereafter the name of the speaker
would be given, together with his subject and the
fact that he whs speaking under the auspices of
the Monmouth County Medical Society. Dr.
Ackerman reported that the subjects and speakers
to date were as follows:
James E. Ackerman
Joseph Ackerman
Albright
F. J. Altsehul
R. Appleton
Joseph Bryan
Byron Blaisdell
J. C. Clayton
W. Campbell
Henry Dorr
S. Edelson
W. H. Fairbanks
D. F. Featherston
James A. Fisher
T. E. Fenton
W. Golsing
W. G. Flerrman
O. R. Holters
Heatley
S. Hausman
W. F. Jamison
L. L. Leonard
Robert MacKenzie
Stanley Nichols
Charles D. Prout
H. G. Thomas
Daniel Traverso
J. Villipiano
W. Von Oehsen
Robert Watkins
Frank Wilbur
George Wilbur
G. V. Warner
Helen Upham
History of Medicine
Influenza
Psychology of Childhood
Life Expectancy
Head Colds
Diabetes
Exercise
State Board of New Jersey
Diet
The Modern Heart
Progress of Medicine
Aviation Medicine
Regarding Mental Develop-
ment of Children
Tuberculosis
First Aid and Fractures
Care of the Nose and Throat
Tetanus
Obesity (Treatment of)
Cancer
Cancer
Communicable Diseases of
Children
Schick Test — Dick Test
Vitamins
Skin Tumors
Ethical Medicine as it Re-
lates to Public Service
Some Interesting Gyneco-
logic Data
Prevention of Disease in
Babies and Children
Prophylactics in Children
Obesity
Something I Ate
Emergencies
First Month of Life
Contagious Diseases
Over-Heating of Houses
Medical Thoughts
The Alleged High Cost of
Medical Care
Women in Medicine
536
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
Dr. James Ackerman brought to the attention
of the society the illness of Dr. J. C. Clayton. It
was voted to send a letter of encouragement and
flowers to Dr. Clayton. Dr. D. M. P. Magee also
mentioned the illness of Dr. Garrison and the
Secretary was instructed to write to Dr. Gar-
rison.
Dr. George Van Voris Warner reported on the
revision of the County Constitution and By-Laws
and read the first draft. The President was to
appoint a committee to review this draft and re-
port at the next meeting.
Dr. W. G. Herrman suggested the formation of
an Executive Committee to handle all routine
business so that the meetings of the society would
be confined to scientific discussions and such busi-
ness as the Executive Committee thought should
be brought before the body as a whole.
The paper of the evening was given by Dr. W.
G. Herrman who spoke on “The X-ray and Ra-
dium Treatment of Uterine Hemorrhage”. The
paper was discussed by Drs. Slocum, Pons, Acker-
man and Featherston.
A buffet lunch was served.
MORRIS COUNTY
Marcus A. Curry, M.D., Reporter
A special meeting of the Morris County Medical
Society was held at the State Hospital at Grey-
stone Park, the evening of Wednesday, April 29.
President Sutphen presided over a very gratifying
attendance of approximately 80, including visitors,
among whom were Second Vice-President Flagerty
of the State Society, and a group of Hudson County
physicians, including Drs. Arlitz, Cobham, Larkey,
Maver and Stuart.
The president introduced the speaker of the
evening, Dr. J. M. Wainwright, of Scranton, Pa.,
Chairman of the Pennsylvania State Commission,
on Cancer, who provided a most interesting talk on
“Interesting Conditions of the Mammary Glands
and Nursing Habits of Native Women and Lower
Animals”, which was illustrated by lantern slides
with pertinent comments and observations.
Dr. Wainwright prefaced his very interesting
presentation by stating that it had not much to
do directly with medicine of any kind but stiil the
more we know of subjects allied to medicine the
better off we will be. He spoke of books having
been written on “From Fish to Man” and “From
Ape to Man” and hoped some day something would
be written about the mammary gland; that he
had gotten up some interesting facts that he would
present more or less disconnectedly.
His illustrations and explanations of the dif-
ferent locations in various animals of the mam-
mary glands, and the evolution which seems to
have brought about a. reduction of the number of
“restaurants” were very interesting and some-
times amusing; the female elephant seeming to be
the only animal that has the udder and nipples
between the forelegs; which he explained
was a provision of nature so that the mother
could supervise and manage any unruly young
with her very useful appendage, the trunk, which
could not be used so efficiently if the “restaurant”
patronized by the young was situated in the ex-
treme rear. He also illustrated and explained
what to the uninitiated were novel locations of the
nipples on what might be termed aquatic animals,
these being on the side, and some up near the back,
so that the young could ride along on the back of
the mother through the water and suffer no in-
convenience with the approach of hunger, and so
that the mother could gad about from place to place
through the water without having to dock and lie
down to enable the young to feed from beneath,
as would be the case with most animals; also of
interest were the mammary functions of some ani-
mals that had no nipples but simply by muscular
contraction exuded the milk to the hair from which
the young licked it and so fed themseives. Also
interesting were the idiosyncrasies of the young
of the pouch animals, where the young go to the
pouch immediately after coming into being and
hang on to their particular gland continuously
until the time arrives for them to let go and main-
tain themselves otherwise; it seeming that if they
should let go they are unable to recover the gland
and they would perish; of further interest was the
situation of the nipples on animals that slither
along on their bellies, they being depressed so that
they will not damage or wear in the process of
travel, such as the seal, etc. While many of us
are familiar with the bat it is unlikely that we are
quite so familiar with the mammary features of
this little bird-animal and the fact that bats carry
their young with them on their flights, the young
holding fast to the nipple with their claws; then
when the mother hangs herself upside down on a
beam for sleep the young bats reverse themselves
and take hold of 2 unfunctioning nipples on the
other end and thus maintain their hold on the
mother bat and on life itself.
Dr. Wainwright’s program provided a novel and
interesting evening and he was given a fine round
of applause, and upon the suggestion being made
he promised to return sometime in the future and
give a talk on the subject of cancer, his capabili-
ties in this respect causing everyone to look for-
ward with anticipated pleasure to that meeting.
Mention was made of the candidacy of one of
our members, Dr. Julia C. Mutchler, of Dover, for
the nomination of Assemblywoman from Morris
County and the sentiment was that it would be in
the interests and for the welfare not only of the
county society but of the physicians of New Jer-
sey if her nomination and election be effected,
which is altogether within the realm of definite
probability.
After the formal meeting Superintendent Curry
of the State Hospital invited the members and
guests to partake of refreshments, which they did
with much enjoyment, in the employees’ cafeteria.
Special May Meeting
A special meeting of the Morris County Society
was held the evening of Thursday, May 21, at
the State Hospital at Greystone Park, with Presi-
dent Sutphen presiding and about 45 members and
guests present.
Preliminary to the main purpose of the meeting,
the President called attention to the annual meet-
ing of the State Society at Asbury Park, June 3-5;
that the golf tournament would be June 3 and for
golfers to communicate with Dr. J. A. Fisher,
Jersey Central Building, Asbury Park: and stat-
ing that we all should be pleased that Doctor Julia
Mutchler, one of our members, won the nomination
for Morris County Assemblywoman; also announc-
ing that 2 applicants for membership, Drs. Ferris
and Falvello, had been approved by the investi-
gating committee and would be voted on at the
next regular meeting.
The feature of the evening was a presentation
by Dr. Joseph Jordan Eller, dermatologist, of New
York: his subject being “The Diagnosis and Treat-
ment of the Common Skin Diseases, with a Dis-
cussion of Precancerous Lesions”. The 3 main types
of skin diseases discussed were dermatoses caused
June, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
537
by various drugs, poisons and toxins; dermatitis
caused by local or internal infections, and derma-
tosis caused by fungi.
Dr. Bart M. James, of Newark, lead the discus-
sion which was also entered into by Drs. Costello,
Christian, Collins, Young, F. Grendon Reed, Gibb,
AJlaben, and the questions asked were fully an-
swered by the speaker of the evening.
After adjournment refreshments were enjoyed
in the cafeteria.
OCEAN COITIVTY
Eugene G. Rerbener, M.D., Reporter
The regular meeting of the Ocean County Medi-
cal Society was held at the Ocean House, Toms
River, May 20, at 6 p. m. Those answering the
roll call were: Drs. Woodhouse, Towbin, Ober, Gold-
stein, V. M. Disbrow, Sawyer, Brouwer, Harold
B. Disbrow, Swan, Denniston, and Herbener.
The President, Dr. Adolph Towbin, called the
meeting to order and extended a greeting of wel-
come to our new member, Dr. ,Ober.
The report of the Committee on Membership
was received and Dr. W. E. Dodd, of Beach Haven,
was unanimosly elected.
Drs. Lieutenant Bruce Bradley, and Lieutenant
Commander William W. Davies, of Lakehurst
Naval Air Station, were elected unanimously to
honorary membership in the society.
Drs. Towbin, Thompson and Swan agreed to
represent our county in the Golf Tournament of
the New Jersey State Medical Society to be held
Wednsday, June 3, at the Asbury Park Golf and
Country Club.
A general discussion of matters of minor im-
portance followed, after which the meeting ad-
journed.
PASSAIC COUNTY
W. W. Flail, M.D., Reporter
The regular meeting of the Passaic County
Medical Society was held at the Health Center,
Paterson, May 8, at 9 p. m. Dr. Carlisle presided.
The minutes of the April meeting were approved
as read.
The following applications for membership were
received and referred to the Board of Censors:
Drs. Morris PI. Saffron, 200 Jefferson Street, Pas-
saic; Jeremiah PI. O’Brian, 204 Madison Street,
Passaic; J. Thompson Stevens, 55 Park Street,
Montclair.
The paper of the evening was presented by Dr.
A. A. Berg, Attending Surgeon, Mt. Sinai Hospi-
tal, New York City. His subject was: “Surgical
Treatment of Diseases of the Colon”. The lecture
was illustrated by numerous lantern slides. Dr.
Berg’s talk was closely followed.
The meeting adjourned at 11 p. m.
UNION COUNTY
Summit Medical Society
W. J. Lamson, M.D., Secretary
April Meeting
The regular meeting of the Summit Medical So-
ciety was held at Wallace Pines on Wednesday,
April 29, at 8.30 p. m., with the President, Dr.
Smalley, in the chair, and Dr. Meeker entertaining.
Present, 19 members and 3 guests.
A paper was read by Dr. Meeker, entitled “An
Outline Study of Endoerines”.
Dr. Meeker gave a comprehensive summary of
our present knowledge on the subject of internal
glandular secretions, symptoms caused by hyper and
hypo-secretion, and the therapeutic use of hor-
mones. Much remains to be worked out, however,
before they can receive thfe value they must ulti-
mately have in the treatment of various conditions
in which they are indicated.
The paper was freely discussed by Drs. Dengler,
Morris, Byington, Prout, Bowles, Jamison, Hal-
lock, Moister and Johnston.
Dr. Byington called attention to the fact that 2
hormones, thyroxin and adrenalin, ai’e already
produced synthetically.
Dr. Morris likes to combine several hormones,
and said it was necessary to continue their use
over a long period of time to obtain desired re-
sults.
Dr. Prout, on the other hand, does not approve
of pluriglandular therapy, but insists that indi-
cations for use should be carefully studied and
then the appropriate hormorie should be given, in
order to test their true value.
Dr. Moister pointed out the fact that, with the-
single exception of thyroid substance, the glan-
dular hormones should be given hypodermically
rather than orally.
May Meeting
The annual meeting of the Summit Medical So-
ciety was held at Wallace Pines, on Tuesday,
May 26, at 8.30 p. m., with the President, Dr.
Smalley, in the chair, and Dr. Hallock entertain-
ing. Present; 24 members and 5 guests.
The election of officers for the year 1931-1932
resulted as follows: President, Dr. Wellington.
Campbell, of Short Hills; Vice-President, Dr.
Joseph E. Pollard, of Chatham; Secretary, Dr.
William J. Lamson, of Summit.
The newly elected President, Dr. Campbell,
then took the chair. The Secretary read an in-
vitation extended to the society to attend the
Graduation Exercises of the Training School for
Nurses, at Overlook Hospital, on June 5.
The Secretary was requested to write and
thank Mr. Thomas J. Watson, of Short Hills, and
his foreman, Mr. William MoCue, for entertain-
ing the members of the society at his farm at
Oldwick, N. J., on May 21, and for the oppor-
tunity of inspecting his model dairy.
A paper was read by Dr. Hallock, on “Factors
Affecting the Length of Pregnancy”.
There is no single standard of estimating this
period — each man having a method of his own —
but all are based on the date of last menstrua-
tion, date of quickening and height of fundus.
The duration is apt to be less in young than in
older women. On account of the uncertainty
of some of the data on which the computation is
made, it is wise to wait until within 3 weeks of
the expected date before inducing labor.
Dr. Hallock described various methods for in-
ducing labor — castor oil and quinin, pituitrin,
bags, bougies, accoucbment force and rupture of
membranes, and cited reports and statistics to
show the desirability of the latter method.
WARREN COUNTY
Charles B. Smith, M.D., Secretary
The spring meeting of the Warren County Medi-
cal Society was held at the Elks’ Home, Phillips-
burg, April 23, being called to order by the Presi-
dent, Dr. Bossard, at 11 a. m.
Members, present: L. H. Bloom, G. H. Bloom, H.
538
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
June, 1931
B, Bossard, G. W. Cummins, Paul Drake, L. 'W.
Hackett, F. J. LaRiew, C. H. Lyon, C. B. Smith,
T. F. Spillanc and A. C. Zuck. Visitors present:
Dr. George N. J. Sommer, Trenton, State Society
President; Dr. F. G. Scammell, Trenton, Councilor;
Dr. Frederick Roberts, of Easton, and Dr. Baldauff,
recently located in Belvidere.
The minutes of the last meeting were read and
approved. It was regularly moved and seconded
that Dr. Baldauff’s application for membership be
accepted and referred to Censors.
The death of Dr. L. C. Osmun, of Hackettstown,
which occurred on March 30, 1931, was reported.
The President appointed Dr. C. B. Smith, of
Washington, as Secretary pro-tem.
The President also appointed Drs. A. C. Zuck
and C. B. Smith to draw proper resolutions on the
death of Dr. Osmun, who had served as Secretary
of the Society for the past 7 years.
It was unanimously agreed that the cost of the
room in Farrell Arms Plaza, Washington, N. J.,
where Post-Graduate lectures are being held, be
paid by the society. It was reported that the lec-
tures were most interesting and practical and
very much appreciated by the members attending.
Dr. T. F. Spillane, of Phillipsburg, was elected to
fill the unexpired term of Dr. Osmun as Delegate
to the State Society. Dr. Osmun was elected on
October 15, 1929, for a term of 3 years.
Dr. Frederick Roberts, chief of the Medical Staff
of the Easton Hospital, read a very interesting
paper on “Bronchial Asthma”, and he was compli-
mented by all the members who took part in the
discussion, also by Drs. Sommer and Scammell for
jn-esenting such an interesting and practical paper
on such a troublesome subject.
After a very good dinner, served at the Elks’
Club, Dr. Sommer gave a talk on what the Society
had done during the past year for its members,
and Dr. Scammell told us how he got his start in
surgery, his first operation being successfully per-
formed on Dr. Reese’s back porch.
Obituaries
LINDLEY', Charles L., formerly of Lakewood,
died at 'Los Angeles on March 26, 1931, in his
seventy-seventh year.
Dr. Lindley was well known in Lakewood where
he took an active part in the professional, social
and sporting life of the resort. Ill health, 10 years
ago, compelled him to take up his residence in
California where, despite his advancing years, he
enjoyed a retired life.
Dr. Lindley was born in Durban, Natal, South
Africa, November 3, 1854. He was the son of
Rev. Daniel Lindley, a missionary to the Dark
Continent, and Lucy (Allen) Lindley, a descendant
of Ethan Allen, of Ticonderoga fame. He received
his early education in a German school in Her-
mann sburg, South Africa, and later studied in
Vienna. He was graduated in 1897 from the Col-
lege of Physicians and Surgeons, Columbia Uni-
versity, with high honors.
SCHUREMAN, James Percy, of New Bruns-
wick, died in the Middlesex Hospital, May 6, 1931,
after an operation for appendicitis. He was 51
years of age and had practiced in New Brunswick
since 1905.
Dr. Schureman was a graduate of Princeton and
the University of Michigan. He was a Captain
in the Medical Reserve Corps, a member of the
Middlesex County Medical Society, the New Jer-
sey and American Medical Associations and a Fel-
low of the American College of Surgeons. He was
on the attending staffs of the Parker Memorial
and St. Peter’s Hospital.
Resolutions oil tlio Death of Dr. Charles J. Cray-
thorne, Adopted by the Mercer County
Medical Society
Resolved. That there be entered on the official
minutes of this society, an expression of the great
loss it has sustained in the death of Dr. Charles
J. Craythorne. In the successful labors of a long
life he has constantly added to the respect and
dignity of our profession. Thoroughness and con-
scientiousness were characteristics of all his work.
These qualities, added to ability and clear judg-
ment, secured for him, in all his professional and
personal relations, the confidence and friendship
of those who have been associated with him.
Resolved, That we tender our sincere sympathy
to his family and, that the Secretary be requested
to send them a copy of these resolutions.
N. B. Oliphant, Chairman
Frank G. Scammell
D. B. Ackley
Resolutions on tlic Death of Dr. Raymond S.
Seibert. Adopted by the Mercer County
Medical Society
Whereas Almighty God has seen fit to remove
from our midst, Raymond S. Seibert, M.D., a. valu-
able member of the medical profession.
Be It Resolved, that in his death this society
has lost a faithful and untiring member of the
profession; a man who served his country in both
peace and war; who spent unselfishly many hours
of service for his fellow-men and in so doing im-
paired his health to such an extent that for the
past 3 years he had been unable to follow his
life’s work. His memory will be cherished by his
fellow practitioners who have adopted this reso-
lution, and ordered that a cojiy be sent to his
family.
Respectfully submitted,
J. FI. McCullough. Sr.
A. W. Atkinson
W. E. D’Arcy
Resolutions on the Death of Dr. William N. Strat-
ton, Adopted by the Mercer County Medical
Society
Whereas the members of the Mercer County
Component Medical Society have suffered a great
loss in the untimely death of Dr. William N. Strat-
ton, one of the valued members of their society;
and whereas because of his kindness of heart
and sincere devotion to the lofty ideals of his pro-
fession, the members of this society sincerely re-
gret his passing;
and. whereas we desire to extend the sincere
sympathy of the society to his family in the loss
of a kind and loving husband and father;
Be It Resolved, that as a mark of the esteem in
which our late colleague was held by this society,
this resolution be spread upon the minutes and a
copy of the same be presented to his family.
M. M. Kent
Harry Berger
F. B. Zandt
539
journal of The Medical Society of New Jersey
Under the Direction
of the Committee on Publication
Vol. XXVIII., No. 7
ORANGE, N. J., JULY, 1931
Subscription, $3.00 per Year
Single Copies, 30 Cents
PRESIDENTIAL ADDRESS*
George N. J. Sommer, M.D., F.A.C.S.,
Trenton, New Jersey
Even if custom did not require it, I am
sure that I should want at this moment to ex-
press to you my appreciation of the honor
conferred upon me in the call to service as
President of this ancient and honorable guild
of physicians and surgeons. I have never
cared especially for antiques merely because
of their antiquity, but I confess to strong ad-
miration of institutions that have continued to
live for a long period of time and which have
maintained consistently and persistently an ac-
tive and praiseworthy existence. To have
been deemed worthy to fill the presidential
chair of the oldest and one of the most dis-
tinguished medical societies in this country,
will ever be to me a happy recollection and I
wish now to thank you, my colleagues and my
friends, for this signal expression of your
faith and trust. I was content to walk in
the ranks of this noble company, but when
you chose me to serve temporarily as captain,
I determined to work in that position as I
would in any other, to the best of my ability,
realizing fully that no other honor, however
great, can ever mean so much to me as does
this one that I now gratefully acknowledge.
As your leader for the past year, the time
has come to render an account of my observa-
tions. At the time when our society inaugu-
rated the plan of having an annual presidential
* (Delivered at the 165th Annual Meeting of
the Medical Society of New Jersey, at Asbury
Park, June 5, 1931.)
address, it was customary to present a dis-
course upon some scientific subject related to
the practice of medicine. Since then, how-
ever. many things have changed and nearly
every aspect of the presidency appears differ-
ent today from the picture 20 years ago. I
could, and felt very much inclined to, speak
to you of some one of the many interesting
surgical questions of the day, but the science
of medicine has gotten so far in advance of
its practice that it seems better to discuss
problems that are more in need just now of
serious consideration. So, following the lead
of some of my immediate predecessors in this
office, I shall devote this time to a short re-
view of my official conduct and present for
your further consideration some of the more
pressing questions now demanding the atten-
tion of organized medicine.
Accepting the task as both a duty and a
privilege, I have during the year visited all
but one of the 21 county societies while in
session, participating when I could in the dis-
cussions of scientific papers and conferring
with them on matters that affected their re-
lationship to the state and national societies.
In addition, I managed to attend 3 of the 5
Councilor District meetings, 3 Tristate Con-
ferences, the Annual Conference of Secre-
taries and Reporters of our own component so-
cieties, and accompanied Morrison and Reik
to the Annual Conference of Secretaries and
Editors of State Societies held in Chicago
under the auspices of the American Medical
Association. The presidency of the American
Medical Association has become a full-time
job. with burdens that weigh heavily in the
balance against the honor of holding that
540
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
office. From practical experience I can tell
you that presidency of the state society is no
longer a sinecure, but is rapidly becoming a
full-time job. My deep personal interest in
the economic as well as the scientific prob-
lems of the day, and my affection for mem-
bers of the medical profession, have, however,
made the work pleasurable.
Those of you who have not had so full an
opportunity to meet with confreres of coun-
ties other than your own, or from other parts
of the nation, may find it difficult to under-
stand why economic problems have suddenly
come to occupy such a prominent position,
but, as was pointed out by the Executive
Secretary in the last of his travel articles,
those who now occupy official positions are
finding themselves in the midst of turbulent
conditions and faced bv controversies, by
prophecies and by threats, that compel thought
and sometimes decisive action. I am not
greatly alarmed by the threats of legislative
action looking to the control of or to inter-
ference with the practice of medicine, but
some of the problems being discussed in lay
magazines and some of those appearing in the
columns of national and state medical jour-
nals. are of sufficiently serious import to re-
quire contemplation and possibly preparation
for organized action. After the recent pro-
posed settlement by Great Britain of an age-
long dispute with India, it was said of the
English Ambassador: “It is an achievement
of Lord Irwin to have robbed India of griev-
ances. In that he has shown great statesman-
ship.” It may be the part of wisdom to settle
some of our controversies by depriving the
public of its grievances, real or imaginary.
At the county society meetings, all over
the state, the economic problem most fre-
quently encountered has been one always in
some manner related to enforcement of the
Workman’s Compensation Law. The very
frequency of the question’s appearing would
seem to indicate that there is much dissatis-
faction resulting from the manner in which
insurance companies deal with physicians in
paying for medical service. Some of the
trouble appears traceable to physicians not
understanding or not complying with the law,
but many instances are reported where action
of the insuring agent, or the employer, seems
to have been arbitrary and unreasonable, and
not infrequently physicians have been disre-
spectful to the rights of one another. An ad-
visory commission, appointed by the Commis-
sioner of Labor, has, after a year of investi-
gation, just made a series of recommendations
designed to improve conditions for those who
handle compensation cases, said report hav-
ing been published in the May Journal.
W hether or not those recommendations, sup-
posing that all will be adopted, will remove all
causes of dispute remains to be seen ; un-
doubtedly, the situation may thus be improved,
but as similar laws are being passed and put
into efifect in other states, differing in some
respect from ours, and as there are many as-
pects to some of the disputes, involving ques-
tions of ethics as well as of economics, it may
not be amiss to provide a special committee to
study the whole problem and to make recom-
mendations in the event that it is considered
desirable to have the law amended. At the
same time we should keep in mind the fact
that New Jersey is now favored by having a
better Workman’s Compensation Law than
other states ; a state of affairs for which the
profession owes thanks to Dr. McBride and
previous welfare committees.
A close second to this problem is that which
concerns the growth of industrial medicine
and contract practice. Here, too, we seem to
be in need of an investigating committee to
ascertain facts upon which action may be
based,. New Jersey, especially in its north-
ern half, is becoming highly industrialized and
with the growth of factories, both in number
and in size, there is developing a form of
medical practice often referred to under the
general term of “industrial medicine”. It has
been pointed out that the medical profession
has for years past encouraged factory owners
and department store managers, for instance,
to employ physicians to take care of their
employees, especially to render treatment in
the event of accidents and emergency illness,
and the employers have learned that it pays
better to keep the employees healthy than to
allow them to become sick from any avoid-
able disease. Having promoted the idea, can
we now declare that physicians engaged in
July, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
541
such work are practicing unethically ? In some
fields of industry this type of practice is car-
ried on under special contract, and thereby
comes under consideration in relation to our
opposition to contract practice in general. Such
contracts were not dreamed of at the time
when our rules were made, and it seems
necessary now to modify the language of those
rules or to issue an interpretation of them
for guidance of those who, by written or
verbal contract, engage in such medical prac-
tice. It is useless to denounce physicians for
doing things that are beneficial to the public,
and which are in themselves both right and
proper, merely because the letter of the code
is against them ; it is the spirit of the code
about which we should be most concerned,
and everybody involved must wish for clari-
fication of this situation. The Mercer County
Medical Society, having this matter under
consideration at a meeting in February 1930,
decided that contracts negotiated by any of
its members should be in accord with the
principle of “covenants openly arrived at”,
and adopted the following resolutions, which
seem reasonable and satisfactory :
(a) This society believes that contract practice,
except such as this society shall sanction as rep-
utable under existing' compensation laws, is at
variance with the Code of Medical Ethics and de-
rogatory to the dignity of the profession.
Therefore, the name of any member receiving
or renewing such contract shall, ispo facto, be
dropped from the roll.
(b) Any member having or considering a con-
tract under existing compensation laws shall pre-
sent a certified copy of the contract to the secre-
tary of the society.
Such contract shall be presented to the society
at a regular meeting, and be referred to the Board
of Censors, who shall consider such contract and
report to the society at the following meeting.
Any member failing to present such contract to
the secretary will be dropped from the roll, after
due action by the society.
(c) Any physician engaged in contract prac-
tice, making application to the society for mem-
bership, shall present with his application a cer-
tified copy of his contract.
While dealing with the general subject of
contract practice, I may be allowed to report
an action taken by the Mercer County Medical
Society with relation to physicians’ holding full
time institutional positions engaging in private
outside practice. Inasmuch as the whole mat-
ter is embraced in a single communication
from Commissioner Ellis, of the Department
of Institutions and Agencies, I will simply
read that letter :
"Dear Dr. Sommer:
The State Board of Control has taken the fol-
lowing action in reference to the consideration of
the work of physicians’ giving full time to the
state institutions:
At a meeting under date of May 27, a resolution
was passed as follows :
‘WHEREAS, the Mercer County Component
Medical Society has brought to the attention of
this Board by resolution its intention to eliminate
from that society physicians employed on full
time in state institutions who receive maintenance
and engage in outside practice, and
WHEREAS, the State Board of Control has con-
sidered carefully the questions involved,
BE IT RESOLVED that we here record our de-
cision that physicians who are employees of state
institutions shall not make use of equipment or
facilities for the treatment of persons not regu-
larly committed to such institutions and that the
use of dwellings or other state property for private
practice is contrary to the policy of the State
Board of Control.'
At the meeting of the State Board of Control on
Tuesday, June 24, the following resolution was
passed :
"Dr. Dowd reported that the State Board Com-
mittee, together with representation of the medi-
cal membership of the local institution Boards,
had conferred with a committee of the Mercer
County Medical Society, and that it was the rec-
ommendation of the State Board Committee that
positions of physicians residing in the institutions
should be clearly set forth as full-time positions,
and that all extra-mural work outside the insti-
tution should be limited to consultation work in
their special fields.
The State Board concurred in the recommenda-
tions made by Dr. Dowd for the committee and
commended the committee for its work in this
connection.’
I have transmitted to the Presidents of the
Boards of Managers of the several institutions
copies of the above resolutions.
The State Board understands that the above
policies were made after conference with the
medical members of the local Boards of Mana-
gers. It is the understanding of the State Board
that the policy as outlined met with the full, cordial
cooperation of the various state institutions and
the professional medical staff of each of the in-
stitutions. It is, of course, the idea of the State
Board that the local Boards of Managers will work
out the administrative details of applying the
policies as outlined in these resolutions.
We all understand the desirability of making it
possible for the professional medical staff of the
institutions to maintain professional contacts of
the consultation type with other men in the pro-
fession.
I will be very glad to have you bring this ac-
tion of the State Board to the attention of the
State Medical Society and the officers of the Mer-
cer County Component Medical Society.”
I wish to express appreciation of the cour-
teous cooperation received in this matter from
Commissioner Ellis, Dr. Dowd and Dr. Ray-
croft.
At the several Councilor District meetings,
542
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
as well as at some of the county society gath-
erings. considerable attention has been de-
voted to economic problems. At the first dis-
trict meeting, held in Newark, the single
topic was “state medicine”. At the second
district meeting, the number of topics was
greater but the principal one concerned recog-
nition and classification of specialists, and
resolutions were adopted to be passed on to
this society. At the fifth district meeting, in
Atlantic City, Dr. John Hartwell, of New
York, discussed this same question and de-
scribed the plan being put into operation at
the New York Academy of Medicine to im-
prove conditions in that city.
One cannot read the numerous magazine
and newspaper articles and the now consider-
able number of books criticizing the medical
profession for laxity in providing safeguards
for the public against unqualified specialists,
without recognizing the fact that some of the
complaints are justified and that even the ex-
aggerated statements used by some lay writ-
ers have a certain foundation in fact. It would
seem to be our duty to give thought to these
matters and to make an attempt, at least, to
meet the wishes of the public with respect to
exerting some control over those members of
the profession who hold themselves out to
be surgeons or specialists, and to provide the
people with some means of recognizing those
physicians whom we consider qualified to
practice as specialists. There is nothing un-
reasonable about such a proposition and we
may better cooperate in the movement than
be compelled to submit later to more regula-
tory laws.
Nor can one read the legislative records of
the past few years without realizing that so-
called “state medicine” may be our fate if
we persist in ignoring problems that require
our help for proper solution. At the most
recent Tristate Conference, one of the speak-
ers called our attention to recent national
legislation extending medical care and hos-
pital privileges to war veterans and their
families, and asked if we realized that by
changing a very few words in now existing
laws state medicine in its full sense could be
established on a national basis.
Our Journal Editor has given us a sum-
mary of the national health insurance laws
now operative in other countries, and has
pointed out the gradual encroachment upon our
own territory. During the earlier months of
this year the states of Massachusetts and New
York both had such laws to fight in their
legislative chambers. We are. apparently, in
no immediate danger but does not that fact
suggest that this is an opportune time to con-
sider these things in order that action may he
taken to prevent the introduction of such acts
— by removing the existing incentive— -or to
prepare for that fight which will otherwise
inevitably come. At the meeting of Secre-
taries and Reporters o*’ Count) Societies, in
Trenton last November, a resolution was
adopted requesting this society to appoint a
commission to study the state medicine prob-
lem ; and at the Second Councilor District
meeting, as I have already stated, resolutions
bearing upon the control of specialism were
adopted for passage along to us. I commend
these resolutions to your careful considera-
tion. There is nothing to be gained by shut-
ting our eyes against obvious facts; much may
be gained by cooperating with other institu-
tions and organizations and by an honest ef-
fort to correct any evils that may be found in
our own practice— thus to deprive critics of
any basis for proposing new legal enactments.
In the matter of legislation, we have suc-
cessfully passed through another year. Our
greatest concern was aroused when the Gen-
eral Assembly had under consideration the so-
called Abell Bills. In an effort to improve
governmental business, the investigating com-
mission presented a group of new laws, most
of which were good, but the mistake was made
of going to extremes in one matter and of
framing an act without full knowledge of its
probable effect. In that matter we were glad
to cooperate with other organizations con-
cerned— especially the dental and pharma-
ceutic associations- — and our joint efforts re-
sulted in prevention of an apparent calamity.
A closer alliance with such other organiza-
tions should be cultivated and I hope will now
be maintained steadily.
Among many propositions that have come
to hand during the year is one requesting our
cooperation with the State Hospital Associa
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
543
tion in asking the Governor to appoint a
special health commission to study and make
recommendations for modernizing the health
activities of New Jersey. We were informed
at the Tristate Conference in February that
a similar commission, appointed by Governor
Roosevelt, of New York, had about com-
pleted a report, after making a survey of con-
ditions in that state. Since that time most of
Governor Roosevelt’s program has been en-
acted into law and we might well profit by
New York's experience. At our last annual
meeting, Mr. Bowen, Director of the State
Department of Health of New Jersey, de-
scribed conditions in this state and asked our
support in bringing about improvements.
Nothing was done about it at that time, and
I think it would be wise to take some action
now ; perhaps through the channels named, co-
operation with the State Health Department
and the State Hospital Association.
The Tri state Conference also had under
consideration a paper written by one of our
own representatives on the question of In-
creasing Fatalities Caused by Automobiles,
and a plan calling for physical examination of
all applicants for a chauffeur’s license was
unanimously adopted. Wre hope you will
adopt the recommendations, which were pub-
lished in the February Journal, and take such
steps as may be necessary to induce the Com-
missioner of Motor Vehicles to put some such
plan into effective operation. Incidentally, let
me say that the importance of these Tristate
Conferences can scarcely be overestimated.
The State Medical Society officers of New
York, Pennsylvania and New Jersey are meet-
ing 3 times a year to consider important ques-
tions that concern the physicians of these
states, and it has been both illuminating and
pleasing to take part in their deliberations.
Our hearty support has been given to the
movement from its inception and I recom-
mend that it be continued.
Observing closely the immense amount of
work being conducted from our Executive
Secretary’s office, I have been tremendously
impressed by the necessity for a permanent
home for this society, with proper equipment
and facilities for housing records, for pre-
serving a working library, for conducting the
Journal, for directing our public educational
program, for all the functions of the organ-
ization including provision for committee
meeting rooms and possibly a hall large
enough to accommodate the society in its
annual convention. This question has been
considered by some of my predecessors and
it has been my pleasure to aid in develop-
ing some plans which we hope may prove
effective in the course of time.
When visiting the county societies, it has
been my pleasure in many instances to attend
meetings of the Woman’s Auxiliary to those
local bodies, and I know something of the
work and plans of the state auxiliary and the
national organization attached to the Ameri-
can Medical Association. This entire move-
ment has developed within a very few years
and can scarcely lie said to be yet well estab-
lished. Its success is going to depend in the
main upon the support given by our own so-
cieties. In states and in counties where the
physicians encourage the auxiliary, there will
surely develop a strong organization with po-
tential possibilities for helping the medical so-
cieties. In states or counties, where such en-
couragement is withheld, progress will neces-
sarily be slow. Where any degree of active
opposition exists, even on the part of a small
minority of the medical society members, the
auxiliary cannot live. I am very earnest in seek-
ing support for the Woman’s Auxiliary, be-
lieving fully that we can trust our wives to look
after our interests as carefully as we would
ourselves. Several years ago a committee was
appointed to serve the auxiliary in an advisory
capacity but it seems desirable now to have
such a committee given the duty of outlining
a policy or course of action for the auxiliai'y,
to cooperate constantly with the auxiliary in
developing its work, and to supervise its ac-
tivities. Our women are interested in our
professional as in our home affairs, and I be-
lieve there is a slogan expressing that interest,
in the phrase — “The home, the profession,
and the public health.” Where county aux-
iliaries are properly established one notices a
544
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
greater sociability and better understanding
among the families of physicians, and there
has also resulted an increase of attendance at
those county society meetings. Effective or-
ganizations, fully functioning, can also help
us in legislative matters, particularly in op-
posing acts that threaten the welfare of our
profession, for the women are quick to realize
that whatever strikes at the income of the
physician necessarily affects the home and
family life of the physician.
When Governor Larson, responding to the
appeal of President Hoover, called a State
Conference on Child Health and Welfare. I
directed our Executive Secretary, Dr. Reik, to
represent this society in the organization plans,
and you have heard from him and from those
of our members who participated in the several
conference sections what results were obtain-
ed. I hope that everything possible will be
done to further the aims and objects of those
national and state conferences and that the
children of New Jersey may benefit from our
help in vitalizing the child health program.
Although it was not directly related to that
program, I might mention here that the Gen-
eral Assembly of New Jersey passed a law, at
its last session, providing for a permanent
commission to care for the crippled children
of this state, and, as one member of that body
must be selected from the State Medical So-
ciety, I have asked the Trustees to name 3
members from which list the Governor may
select one for appointment.
During the month of May I attended the
Eighth Annual Conference of Midwives,
sponsored by the Bureau of Child Hygiene,
of the State Department of Health, directed
by Dr. Julius Levy, and Dr. Reik attended
the Conference of Nurses of the Child Hy-
giene Bureau, and both of us were impressed
by the good work performed by that Bureau.
It was pleasing to learn that there are now
no unregistered midwives in this state ; that
these practicing midwives are keen for post-
graduate courses of instruction and strive to
win approval of their study and accomplish-
ments; and that the spirit of cooperation be-
tween these inspectors and the midwives is
perfect. I trust you will keep in mind the
fact that the midwife is an essential factor
in the obstetric field and that it is our duty
to aid in her education and to promote fur-
ther development of the plans so well started.
Some of the hospitals might offer the use of
their facilities as have the 2 institutions that
now provide courses in midwifery.
One of my first official acts consisted in
taking the liberty of inviting the 3 vice-
presidents to sit ex-officio in all Welfare
Committee meetings. I believe the plan has
worked satisfactorily and that it should be-
come a fixed feature. It affords an oppor-
tunity for the vice-presidents to become ac-
quainted with the problems confronting the
organization and to learn about the details of
organization work, so that when they reach
the presidential chair they will be fully in-
formed as to their duties and obligations.
The Welfare Committee is a very im-
portant factor in our organization, and I
wish to thank that Committee, and particularly
its Chairman, Dr. Lippincott, for the excel-
lent service rendered this past year. So, too,
would I thank the Field Secretary, Mrs.
Tanevhill, for the effective manner in which
she has carried to the public our campaign of
public education in preventive medicine.
In closing this review of my service, I
wish to acknowledge my indebtedness to all
those who have assisted in making my admin-
istration a success. Particularly do I offer
thanks to the Secretary, Morrison, and the
Executive Secretary, Reik, for their guidance
and cooperation. Presidents come and go;
the tenure of office is short, and usually the
president enters into office ignorant of his
duties and responsibilities. Secretaries, if
they be good ones, are retained in office and
become the embodiment of all the knowledge,
history of the past, and methods of procedure
so important to the smooth running of an or-
ganization. We are fortunate in having 2
such reliable, loyal and efficient secretaries,
with whom it has been a pleasure to work.
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
545
THE GENERAL PRACTITIONER AND
OBSTETRICS*
Samuel A. Cosgrove, M.D.,
Jersey City, N. J.
It is furthest from my desire, as one who
perhaps pretends to specialization in obstetrics,
to “talk down” to the general practitioner, for
2 reasons :
First, the specialist obstetrician must or-
iginally be, and must remain, a general prac-
titioner. He is treating human beings who
are subject to the varied ailments which all hu-
man beings of their sex and age group are. In
many cases, the fact of their pregnancy is
hardly more than incidental ; in many others it
is of importance chiefly by reason of its effect
on some other clinical condition present. So
that there commonly come under the care of
the obstetrician, cases of biliary tract disease,
gastric conditions, diabetes, appendicitis, colitis
and hemorrhoids ; of endocarditis, myo-
carditis and vascular disease ; of pyelitis,
nephritis and uremia; of pneumonia, pulmon-
ary tuberculosis, scarlet fever, erysipelas,
meningitis, malaria and septicemia; of chorea,
hyperthyroidism, neuroses and psychoses. He
encounters dangerous hemorrhage and shock
more often than the traumatic surgeon and
has to be as thoroughly at home in pelvic
pathology and intraperitoneal manipulation as
the gynecologist. So that it is as one to an-
other that he talks to general practitioners.
On the other hand, in his devotion of time
to the larger obstetric material which it is
his privilege to serve, he largely loses his
finesse in handling all these other varied ills
of mankind, and must perforce avail himself
constantly of the help of internists and sur-
geons. So that my admiration is large for
the man who, handling his obstetric cases
•competently, just as competently handles
without aid his cases of diabetes, pneumonia,
syphilis, fractures, appendicitis and heart dis-
ease.
Secondly, obstetrics belongs largely to the
*(Read at the Osier Society meeting, Jersey City,
February 17, 1931.)
general practitioner. Statistics are not com-
piled specifically for the purposes of this talk,
therefore it is hard to arrive at close calcu-
lations of just how largely this is true. Guesses
sufficiently close can be arrived at, however.
In 1930 there were in the state 68,325 living
births. The proportion of midwife deliveries
throughout New Jersey is 14.8%; so, 58,211
births were attended by physicians. Probably
about 18% of these occurred in institutions.
If we assume, an assumption not of course
valid, but convenient at this time, that all of
the institutional births were attended by
specialists, and that none of those outside of
institutions were, we find that 47,829 births,
or 70% of them all, were cared for by general
practitioners in the homes of patients, which
is no mean score for the general practitioner.
This may logically prompt the question as
to how well the general practitioner is doing
his obstetric job. No absolute answer can be
made to this, nor are invidious statements
necessary, nor intended. In general, a man’s
obstetric practice is on a par with his other
work. A careless medical man will do care-
less midwifery; one who lacks a conscientious
attitude toward his other patients will show a
similar lack toward his pregnant ones ; one
who takes a careful history on, and com-
petently examines and watches, his stomach
cases, will warrant the confidence of his ex-
pectant women ; one who cares enough for his
work to train himself to deft, gentle manipu-
lation of gall-bladder and stomach is apt to
have proper regard for the soft parts of the
parturient, and to handle the fetus gently and
skilfully. I am inclined to feel that the
graduate of the last few years has had oppor-
tunities for undergraduate and hospital train-
ing that my own student years did not afford.
Therefore, other factors of capacity and per-
sonality being the same, the young practi-
tioner of today should be a better one, and his
obstetrics should be better, than was the case
a generation since. And I am sure, from my
own observation, that these things are true.
Not so often does one hear, as formerly, of
doctors engaging confinement cases with no
expectation of seeing the patient again before
labor starts. Doctors, young and old, are watch-
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
DIG
ing their pregnant women more closeiy and
intelligently than they used to and the change
is of tremendously beneficial importance to
womankind. For in obstetrics as in other
fields of medicine, prophylaxis is the true key-
note of enlightened practice. The salvage of
maternal and infant lives dependent on alert
watchfulness in the prenatal period is directly
proved. In New York State, in 1930, while
the uncontrolled neonatal mortality was
42:1000, that in the group of mothers known
to have been under good prenatal supervision
was 28:1000. This would mean a saving of
957 babies in 1 year, in New Jersey, if such
supervision could be extended to all pregnant
women. The statistics from all centers where
prenatal care has been established indicate an
equally salutary improvement in the incidence
of life-threatening conditions in mothers,
notably in relation to severe toxic conditions.
In the actual conduct of labor the prac-
titioner encounters his greatest test, for it in-
volves diagnostic acumen and judgment, me-
chanical dexterity sometimes of high order,
and the maintenance of surgical cleanliness
under difficult conditions. A local practitioner
of gracious memory who served very many
women in child birth, is reported to have said
that there were 2 classes of labor cases : Those
which needed no doctor, and those which
needed 2. While somewhat inaccurate, as
such aphoristic statements generally are,
it indicates at least 2 important truths. The
majority of labors will terminate spontane-
ously and will need no doctor to meddle with
the normal processes of Nature’s own me-
chanics; 100 years ago Ramsbotham, of Lon-
don, reported 19,439 deliveries in 8 years, with
the following “difficulties and irregularities’’:
Adherent and retained placentas 135
Forceps extractions 35
Craniotomies 25
Vectis cases 1
Difficulties due to transverse presentation,
etc., presumably relieved by version 68
A total of 264
or an incidence of operative delivery of only
1.35%. This demonstrates the fact that in
nearly all cases women can actually extrude a
conception product, even at term, without arti-
ficial assistance, if they have to. Unfor-
tunately, Ramshotham’s table does not give
the average duration of labor, maternal mor-
tality. fetal mortality, nor the cost to mothers
in terms of invalidism of such extreme con-
servatism, though he does confess to 5 rup-
tures of the uterus and 1 of the broad liga-
ment. Certainly it is to be feared that today
such over-conservatism would not be popular
with the ladies.
As perhaps fairly typical of present prac-
tice, on my own service at Jersey City Hos-
pital in 1930, in 1784 del iveries there were :
Adherent and retained placentas 12
Forceps extractions 241
Craniotomies o
Versions 35
Cesarean sections 25 — 1.1%
Hysterectomy . . 1
Total incidence of operative delivery 314 or 17%
Of this series, the maternal mor-
tality was 0.67%, the neonatal 3.3%
The incidence of forceps delivery in this
series is artificially high, due to extensive ex-
perimentation during this period with spinal
anesthesia and “elective” use of forceps. A
normal incidence of forceps operations would
reduce the total operative incidence to about
9%.
1 bus we see that even in the face of easier
recourse to operative delivery of present day
practice, 90% or more of cases will deliver
spontaneously, requiring of the medical at-
tendant wise watchfulness and estimation of
the situation, the maintenance of cleanliness,
the moral support of the patient and her
friends, her protection from excessive soft
tissue damage, the repair of that which does
occur, the exhibition of pain palliative agents,
and appropriate care of the new-born. This
sounds like, and is, a great deal, and would
seem to give the lie to the statement quoted
that such a case does not need a doctor.
But a well-trained nurse-midwife might do
all or nearly all of it competently. And the
doctor errs most frequently in not being con-
tent to do only these things. The most fre-
quent valid criticism of him is, that goaded
by his own limitation of time and the impor-
tunities of the suffering woman, he is too
ready to resort prematurely to operative de-
livery in cases quite capable of spontaneous
termination if reasonable patience be ex-
July, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
547
ercised. The most frequent error observed in
consulting practice is the "employment of for-
ceps before there is full engagement of the
head or full dilatation of the cervix.
In reference to the last statement I would
particularly stress certain definitions'. Full en-
gagement of the head signifies such a degree
of moulding that the maximum plane of the
head must coincide with, and occupy, the least
plane of the upper strait of the pelvis. Until
this takes place the head cannot be extracted
with forceps without undue trauma. If ad-
ditional time for spontaneous moulding fails
to attain this object, cesarean section must be
considered as an alternative, unless contra-
indication exists to the latter procedure. Yet
in many cases, before the greatest diameter
of the head is actually engaged, the elongated
peak thereof will be well down in the pelvis,
and give to the person of limited experience a
false estimate of the progress of accommo-
dation to the inlet.
The complete dilatation of the cervix is in
itself a good gauge of the complete moulding
and partial descent of the head. It must he
not only dilated, but retracted, so that no por-
tion of it can be felt around the head except
perhaps a small segment anteriorly.
Only in the presence of such conditions
should the forceps be used without the grav-
est consideration. For to do so endangers the
integrity of the cervix and the contiguous soft
parts, and constitutes a grave jeopardy to the
baby. Yet, frequently one receives in the hos-
pital or sees in consultation cases in which
these inhibitions to the use of forceps have
been disregarded with pitiable results.
Morphin or one of its equivalents is the
great conservator of the natural expulsive
forces which will frequently convert a dif-
ficult, dangerous, so-called “high forceps” ex-
traction into a relatively safe and much sim-
pler operation.
This brings us to the second part of the
aphorism quoted above, to the effect that a
case needing operative relief “needs 2 doc-
tors”. Is this true? Yes, emphatically. There
are vaudeville performers who win applause,
and. one hopes, a livelihood, from their abil-
ity to play a whole orchestra of instruments
at once, all by themselves. But for a man
conducting any manipulation upon which 2
lives depend, to attempt alone to perform the
duties of anesthetist, assistant, instrument
nurse and operating surgeon, is fool-hardy in
the highest degree. No young practitioner is
too poor to pay the extra expense for help,
himself, if necessary ; no old practitioner is so
extra good that he can always get away with-
out it successfully. I know, because I have
been all the things named ; young — poor —
foolhardy — and am getting old.
Ideally, of course, all such cases should be
institutionalized. In saying this I know the re-
luctance of certain types of people to leave
their homes under even urgent circumstances.
This can usually be overcome by sufficiently
strong representation of the situation, how-
ever, especially if backed up by a threat to
otherwise resign the case. It may be urged
that closed staff arrangements in the several
hospitals preclude universal reference of com-
plicated cases to institutions, yet there have
always been available for financially compe-
tent patients, accommodations in institutions
with “open” or “courtesy” privileges extended
broadly to the profession. In cases financially
incompetent the desire to retain the case at
the sacrifice of the patient’s interest may be
more selfish than conscientious.
The conservation of the physician’s time
and nervous energy in having his patient un-
der competent nursing observation, the as-
sistance of interns, and the facilitation of his
own work by adequate equipment, will pay
him for insistence on institutional care apart
from considerations of his patient’s welfare.
Finally, I think the practitioner should re-
member that obstetricians are available for
consultation. Recently a physician said to me
— “I always feel stultified in calling an ob-
stetric consultant.” I said: “Why? You would
not hesitate to call an internist in a case of
pneumonia for which it is probable you would
lie doing all that he could suggest your doing.
Certainly you would promptly call a surgeon
should you diagnose acute appendicitis or
mastoiditis. In neither case would you feel
‘stultified’ nor would your patients impute in-
capacity to you. To feel differently about an
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
548
obstetric case presenting unusual difficulty, is
either to deny equal importance to a matter
involving 2 lives or to deny to all your col-
leagues experience and dexterity possibly su-
perior to your own.”
Obstetrics should be conceived by the gen-
eral practitioner, not as a necessary nuisance,
but as an important, dignified branch of medi-
cine belonging peculiarly to him, worthy of
his most painstaking, conscientious service,
in which he should avail himself when neces-
sary of the cooperation of experts to the end
that mothers and babies may receive the full-
est benefits that modern surgical science is
capable of affording them.
CONSIDERATION OF THE CAUSES OF
DIARRHEA*
E. W. Rodman, M.D.,
Beverly, N. J.
When the term “diarrhea” is used one im-
plies a lessened consistency and usually an in-
creased frequency of the stools. The lessened
consistency need not be extremely marked, be-
cause we may consider it as diarrhea where
there are but a few soft stools in which mucus,
pus or blood is noted. Diarrhea includes
not only the forms due to disease of the gas-
tro-intestinal tract but also those due to con-
ditions arising outside of the tract, such as
are observed in toxic states and in disturb-
ances of the nervous system of a functional
nature. Loose movements are usually caused
by stimulation of the bowel due to increased
peristalsis which may be found in both the
large and small intestine. Irritating sub-
stances may cause the fluid contents to be
carried rapidly into the colon, preventing ab-
sorption in the small intestine, or causing an
outpouring of water from the blood into the
bowel with increased production of fluid or
mucus. Again, the increase in peristaltic
movement may be due to lesions in the bowel
itself, such as inflammatory changes, ulcer-
ations, growths or obstructions.
‘(Read at the Burlington County Medical So-
ciety meeting of January 14, 1931.)
In studying the causes of diarrhea it is im-
portant to determine the intestinal site of the
disturbances and note whether or not the per-
istalsis of the small bowel is increased with that
of the large. When diarrhea originates in the
small intestine the stools show an acid re-
action, food particles poorly digested, mucus
intimately mixed with the feces, and unre-
duced bile pigment. When it originates in the
large intestine the stools show usually an alka-
line reaction, food particles well digested, free
mucus and reduced bile pigment.
Like most other medical subjects, the diar-
rheas may be divided into acute and chronic
forms. Most of the acute forms will fall into
1 of 4 large groups :
(1) Diarrhea due to improper food. In-
discretions in diet with a resultant gastro-
enteritis are often followed by diarrhea. The
food may be coarse, improperly prepared, not
thoroughly masticated, taken in too large
quantities, or too hot or too cold. A violent
diarrhea usually accompanies food poisoning
from tainted meat, sausage, milk, fish, spoiled
vegetables and food infected with various
microorganisms.
(2) Diarrhea from intoxication other than
foods. This condition may be caused by poi-
sons or medicine. Drugs such as mercury and
arsenical preparations, and drastic purges such
as jalap, senna and podophyllin are examples.
Poisons such as phosphorus, mineral acids,
alkalies and bichloride of mercury may cause
acute diarrhea when taken internally.
(3) Diarrhea in acute infectious diseases.
In acute infectious diseases, like measles, in-
fluenza and pneumonia, diarrhea is often
secondary to the associated gastro-enteritis.
The specific infections in which diarrhea is
preeminent are typhoid, cholera and dysen-
tery.
(4) Diarrhea from nervous influences. This
type of diarrhea is a result of either excessive
stimulation of the nerves controlling peris-
talsis or from the pouring out of serous ma-
terial into the bowel, produced by nervous in-
fluences.
1 he stools in acute diarrhea are frequent
and watery, contain mucus and undigested
food, and there is generalized abdominal pain.
July, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
549
lack of appetite, weakness and malaise. When
there is an associated gastro-enteritis the
nausea and vomiting may overshadow the in-
testinal condition. In severe cases, fever and
albuminuria are present and an alarming state
of weakness may ensue. Nervous diarrhea
usually has a sudden onset and terminates
rapidly. This condition often appears in in-
dividuals in normal health when overworked
or under a strain, as for instance in students
preparing for examinations. There may be a
few or many watery, thin stools a day with a
small amount of mucus and undigested food
particles.
It is extremely difficult to arrange a satis-
factory classification of the varieties of
chronic diarrhea. The causes are many, and
today with the finer methods of diagnosis the
group is an extremely large and diversified
one. Moreover, no matter what classification is
made, some of the groups will be very similar
and will overlap, and this increases the diffi-
culty in differentiation. The following is the
classification of Friedenwald and Morrison,
based so far as possible on etiology of the con-
dition.
Diarrhea due to achylia gastrica. While
about 30% of the patients affected with
achylia gastrica present diarrhea, it may also
occur as a result of the diminution of gastric
secretion in chronic gastritis. It is believed
that owing to the lack of digestion in the
stomach, caused by the lack of HC1 and the
lessened pepsin secretion, undigested food is
thrown quickly into the bowel and acts as a
mechanical irritant. It also often happens
that because of impairment of activity of the
pancreatic secretion, due to the absence of
HC1, fermentation occurs in the intestine
and produces diarrhea. In the early stages
diarrhea is intermittent with periods of
well being extending over days or
weeks; it soon becomes more frequent, until
it is almost constant. Often, most of the stools
occur before noon, are yellow in appearance,
foul smelling, and contain undigested food,
mucus, and sometimes blood. A fractional
gastric analysis reveals an absence of free
HC1.
Diarrhea due to disturbances of pancreatic
function. In diseases of the pancreas there
are often large irregular stools with alternat-
ing constipation and diarrhea. Deficiency or
absence of pancreatic ferments may be deter-
mined by use of a duodenal tube, and a con-
stant absence of one of them is, according to
Einhorn, indicative of chronic pancreatitis.
Here we have marked diarrhea, emaciation,
colicky pains, and often sugar in the urine.
Diarrhea is often intense in carcinoma of the
pancreas, with occasional fatty stools. After a
time jaundice appears, the liver enlarges and
becomes nodular, the urine contains sugar, and
cachexia is evident. This affection is so fre-
quent that whenever a persistent diarrhea is
observed in a person over 40 years of age,,
which cannot be accounted for by the usual
causes, carcinoma of the pancreas should be
borne in mind. Pancreatic cysts give rise to>
diarrhea not only on account of the disease
present in the pancreas, but also due to the
pressure on the abdominal organs as well.
Diarrhea in disturbed liver function. In a
small percentage of cases of disturbances in
hepatic function, diarrhea appears, but consti-
pation is the rule. Cases described as bilious-
ness or “torpid liver", the Lyon method of
nonsurgical drainage of the biliary tract has
shown to be due to infection in atonic gall-
bladders. These patients are sallow in ap-
pearance, weak, affected with indigestion, and
are frequently the subjects of sick head-
aches and migraine attacks. Constipation is
usual, but a certain few have identical
symptoms with the exception that the consti-
pation is replaced by diarrhea. In Weil’s dis-
ease, together with the chills, fever, headaches,
muscular pain, jaundice and gastro-intestinal
disturbances, diarrhea is usually present. It
is not uncommon in active and passive con-
gestion of the liver and also in atrophic and
hypertrophic cirrhosis.
Diarrhea due to chronic intestinal catarrh.
Chronic enterocolitis often results from an
untreated or unhealed acute catarrh ; it is often
caused by an abuse of laxatives and errors in
diet. There is usually a persistent diarrhea
extending over several years with frequent
acute attacks associated with pain and tender-
ness over the colon. The stools are thin, wat-
ery, offensive, contain considerable mucus and
vary from 3 or 4 to 8 or 10 a day. In intes-
550
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
tinal fermentative dyspepsia, carbohydrates
are digested imperfectly, and the undigested
matter undergoes fermentation, becoming
acid, producing gas and giving to the stools
a putty, foamy appearance with very sour
odor. In addition to the diarrhea, abdominal
pain, gurgling and distention are often noted.
This condition may be primary disease or
secondary to catarrhal affections of the intes-
tines or to achylia gastrica.
Ulcerative colitis, sigmoiditis and proctitis.
Of the ulcerations of the large bowel leading
to diarrhea the most frequent are entamebic,
bacillary, tuberculous, syphilitic and carcino-
matous.
Entamebic dysentery. This is a frequent
form of dysentery, and the entameba should
be looked for in all cases of chronic diarrhea.
In doubtful cases the organisms are best ob-
served in scrapings obtained from ulcerations,
through the proctoscope. In this disease there
are 10 to 20 stools a day containing mucus, pus
and blood. When the stools are passed the
patient is affected with colicky abdominal
pains, often associated with tenesmus, and in
addition there are fever, emaciation and ex-
haustion.
Bacillary dysentery. The symptoms are
similar to those in the entamebic form with
the exception that the bacilli are found in the
stools and will agglutinate with the blood
serum.
Tuberculous ulcerations. Tuberculous ul-
cerations are very common complications of
chronic pulmonary tuberculosis, and the diar-
rhea is most pronounced when the lesions are
in the lower bowel. Pain is a frequent symp-
tom, occurs in the lower abdomen, and is most
severe before the passage of a stool or after
taking food. Mucus is mixed with the stools
and there is also usually a small quantity of
blood. The finding of tubercle bacilli in the
stools is of little diagnostic significance. In
some cases the tuberculosis is localized about
the ileocecal region, and a mass is frequently
felt resembling a malignant growth. In these
cases, in addition to the paroxysmal pain,
diarrhea alternates with constipation.
Syphilitic ulcerations. Luetic ulcerations of
the small bowel are very rare, the most com-
mon being in the rectum. The picture is very
characteristic; the ulcer is elevated, with in-
durated edges and a smooth base, and there is
some stenosis of the bowel which gradually
increases. A positive Wassermann reaction
makes the diagnosis more certain. There is
usually diarrhea, but the stools may be semi-
solid ; considerable amounts of mucus and
sometimes shreds of tissue are found. The
appearance of large amounts of blood is rather
rare.
Carcinomatous ulceration. This may occur
in any part of the colon. Symptoms of in-
complete obstruction appear early and are
manifested by attacks of colic associated with
constipation ; soon, blood or bloody stools ap-
pear from the ulceration. When the neoplasm
is in the rectum there is usually a constant
desire for bowel evacuation, accompanied by a
discharge of gas with mucoid material. As
the condition advances, ulceration appears and
there is a marked diarrhea of small waterv
stools containing blood and mucus.
Mucous colitis. There are 3 theories con-
cerning the etiology of this disease; first, that
it is entirely a nervous affection and that the
mucus is purely a nervous hypersecretion ; sec-
ond, that it is due to a catarrh of the bowel ;
and third, that the disease is due to both a
nervous irritation and a catarrhal condition.
The signs noted are frequent attacks of col-
icky pain in the abdomen, expulsion of
mucus in the form of a membrane, and often
diarrhea. The liquid movements always con-
tain much mucus in the form of shreds, bands,
or even complete casts of the bowel.
Simple colonic infections. Among infections
of the bowel that may give rise to persistent
diarrhea (not including the amebic and bacil-
lary forms) are various microorganisms, in-
cluding tapeworm, hookworm, whipworms,
flukewornis, strongyloides, and various flagel-
late parasites. Diagnosis can usually be made
by careful examination of the stools. The diar-
rhea usually appears suddenly and without
any apparent cause ; stools are evacuated with
much gas, but without pain, and are alkaline,
soft, contain mucus and blood, and have an
ammoniacal odor.
Intestinal obstruction and stasis. When the
obstruction is incomplete, constipation alter-
nating with diarrhea is found. Together with
July, 11)31
JOURNAL OF THE MEDICAL
SOCIETY OF NEW JERSEY
551
the diarrhea there is abdominal distention, colic
and difficulty, and often inability, in expelling
gas. As the bowel becomes almost completely
blocked, dilatation is observed in the area above
the obstruction and the diarrhea is increased
inasmuch as onlv liquid stools pass the ob-
structed area. There are 3 well marked varie-
ties of intestinal stasis that may give rise to
persistent diarrhea. In the first the stasis is
due to a dilated cecum, often in connection
with a dilated colon. Because of the retention,
fermentation is produced which is followed
by diarrhea. In the second variety, on account
of prolonged retention, the fecal masses are
so channeled that the stools pass through in
diarrhea form ; periods of diarrhea accom-
panied by abdominal pain and distention are
not uncommon. When the irritation extends
over a long period of time, catarrhal condi-
tions of the bowel are very common, and as a
result of mjurv to the mucosa ulcerations may
occur which further increase the tendency to
diarrhea. In the third form of stasis, the
diarrhea is due to a spastic condition of the
bowel, giving rise to a frequent passage of
small round fecal masses. The lower bowel is
constantly filled with these masses, and irri-
tability is produced with frequent desire for
defecation with passage of watery stools con-
taining mucus.
Chronic appendicitis. It is sufficient to men-
tion in passing that rarely diarrhea occurs
when a chronically inflamed appendix is
plastered against the bowel.
Diverticulitis involving the sigmoid and
rectum; polyposis of the colon. Diverticulitis
is associated in its early stages with consti-
pation, abdominal discomfort and a general
distention from gas ; after a time, however,
the constipation is often alternated with diar-
rhea and pain becomes localized in the region
of the sigmoid, producing symptoms like those
of appendicitis but on the left side. I he lower
bowel is filled with fecal masses which give
frequent desire for defecation. Multiple
polyps of the colon often give rise to severe
diarrhea and hemorrhages. The movements
are watery and consist largely of mucus and
blood.
Lesions of the brain and spinal cord. Diar-
rhea is frequently noted in cerebral hemor-
rhage, brain tumors, tabes, and transverse
myelitis, the severity of the diarrhea varying
with severity of the central involvement. Die
slightest pressure exerted by the patient is
often followed by the passage of liquid stools ;
a cough or a sneeze may bring about a similar
result and in some instances the movements
may pass when he urinates or walks; in oth-
ers he may be unaware of the bowel discharge,
the stools passing unconsciously in liquid
form.
Disturbances of the , glands of internal
secretion. The diarrhea in hyperthyroidism
and in disease of the suprarenals has been ex-
plained by the fact that due to a disturbance-
in the internal secretions of the glands s.
hyperperistalsis is produced. As has been noted
above, diseases of the pancreas produce diar-
rhea, the large fatty stools aiding in diagnosis,
Diarrhea due to cardiorenal disease. In
myocardial insufficiency, diarrhea is a fairly
common symptom, due to the general passive
congestion of the abdominal organs. That of
nephritic origin is probably due to excretion
into the bowel of irritating toxins, because the
severity of the diarrhea usually varies with
the exacerbations of the nephritic disease. In
patients suffering with chronic nephritis over
a long period of time, uremic ulcers have been
observed in both the small and large intestine.
Diarrhea associated with disturbed metab-
olism. Pellagra, sprue and gout are the dis-
eases in this group often accompanied by diar-
rhea. In pellagra it is usually very severe and
is accompanied by pain. The stools are either
serous or bloody and often contain undigested
food elements. In the late stages of severe
cases an uncontrollable diarrhea occurs, which
is a great factor in the final prostration. The
diarrhea in sprue is very characteristic. At
first it is accompanied by pain and tenesmus,
the stools being liquid and dark; later the
movements occur usually in the early part of
the day and the pain and tenesmus disappear.
The stool is copious, frothy and fermented,
light in color and acid in reaction. Ulcerations
of the colon may also play a part in the
652
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
causation. Gout is rarely complicated by diar-
rhea, but when it is, other gastro-intestinal
symptoms may be present, such as foul breath,
furred tongue, flatulence and abdominal pain.
Cholecystectomy. In a small percentage of
cases there is a persistent diarrhea, the exact
nature of which is unknown, but it is thought
to be due to disturbed pancreatic secretion,
since it has been found that the duodenal con-
tents are deficient in ferments in these cases.
Gastro-enter ostomy. Diarrhea may appear
almost immediately after operation and is
thought to be caused by the rapid discharge
of undigested food into the bowel, setting up
a mechanical irritation.
Pyloroplasty. The cause of the diarrhea in
these cases is similar to that in gastro-enteros-
tomy but is never as severe.
Appendectomy. Removal of a chronic ap-
pendix is occasionally followed by a profuse
diarrhea, due most likely to some injury to the
adjacent bowel occasioned by the operation.
Resection of the bowel. Often severe diar-
rhea follows this operation, and is sometimes
very alarming. It is not difficult to explain
if the severe nerve injury inflicted upon the
intestines by the operation is borne in mind.
Nervous influences. These forms of diar-
rhea have their onset often after severe ex-
citement, worry or shock. The trouble is
caused by hypermotility of the bowel, the
stimuli being either psychic or reflex or a
combination of both. The psychic variety is
produced by worry or shock, while the reflex
form occurs as a result of stimulus like sud-
den chilling of the body. The onset is sud-
den, with gurgling sensations in the abdo-
men, while the patient is in good health. Be-
tween the attacks there is no discomfort and
all varieties of food can be eaten without
causing recurrence. An examination of the
stools shows no abnormal constituents, and
there is very little fermentation. On account
of the increased motility, undigested food par-
ticles may be found.
TREATMENT OF BRIGHT’S DISEASE*
Rolfe Floyd, M.D.,
New York City.
It is my purpose to define some of the prob-
lems that arise in the treatment of Bright’s
disease and to indicate how and to what ex-
tent they may be solved. The conditions with
which I shall deal are convulsions, uremia,
dropsy and hypertension.
Convulsions. The convulsions of Bright's
disease have been called uremic for 3 gener-
ations and believed to be due to poisoning of
the brain by excess of nitrogen waste. In the
last 2 decades this conception has been stead-
ily losing ground for the following reasons:
(1) The closely similar convulsions of
child-birth are now known not to be uremic.
(2) Many chronic nephritics die of uremia
without having had convulsions. (3) Convul-
sions are frequent in acute Bright’s disease
when there is little or no uremia.
Volhard believes, and many are in partial
or complete accord with him, that most con-
vulsions in Bright’s disease are due to inter-
ference with the hloocl flow to the brain. This
interference is thought to be brought about in
2 ways: (1) by spasm of the cerebral ar-
terioles often superadded to a preexistent gen-
eral hypertension; (2) by edema inside the
skull compressing the brain and its vessels.
Volhard states, and my experience coincides,
that patients with general anasarca are less lia-
ble to intracranial edema than those that have
slight puffiness of the face and little dropsy
elsewhere.
When there is edema inside the skull lum-
bar puncture often works excellently. A boy
on my service with acute Bright’s disease had
many convulsions within a few hours, increas-
ing in violence and threatening life. He had
another while lumbar puncture was being
done but no more after that. When lumbar
puncture fails, venesection should be at once
resorted to? In cases that seem to be due to
spasm of the cerebral arterioles a prompt re-
*(Read at the Passaic County Medical Society
meeting of February 12, 1931.)
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
553
duction of blood pressure is the indication and
venesection the method of choice. Chloral
and a quiet room are important after either
puncture or blood letting.
The great majority of convulsions can be
successfully handled in this way, but I do not
wish to convey the impression that we yet
know just how they are caused or that retain-
ed poison is not a factor in some of them.
Uremia. This condition has been supposed
to mean certain nervous and bodily symptoms
due to poisoning by abnormal amounts of
nitrogenous waste accumulated in the body
through failure of the kidney to excrete them
fast enough, but this primary conception has
had to be modified in 2 ways : First, all the
nervous symptoms are not due to nitrogenous
waste, but quite a proportion result from a
reduced blood supply to the brain. Hence,
symptoms due to nitrogenous waste have been
called “true” uremia, while those due to other
causes have been called “false’ uremia. It is
only of the “true” uremias that I wish now
to speak. Secondly, none of the known
nitrogenous waste substances causes uremia
when artificially introduced, so the toxic sub-
stance is yet unknown, but it occurs in quite
definite proportion to those that are known.
Hence, uremic symptoms hardly occur until
the NPN, which is normally about 25 mg. to
every 100 c.c. of blood, passes 100 mg. This
figure is not absolute but is a convenient one
to remember. On the other hand, uremic
death hardly ever occurs below 250 mg. and
may not occur till 500 and over is reached. So,
while estimation of NPN is an invaluable
guide, it is not an actual measure of the toxic
substance itself. It is as impossible to treat a
uremic intelligently without blood chemistry
determination as it is to treat a cardiac irregu-
larity without an electrocardiogram.
There are 2 main ways in which NPN in-
creases in the blood which depend on 2 sep-
arate functions of the kidney in dealing with
nitrogen waste. The separation of these func-
tions is not sufficiently explained in most
books on the subject yet an adequate under-
standing of the treatment of true uremia de-
pends on proper understanding of these 2
functions and of how they interact.
In the first place, the kidney extracts urea
from the blood, and in the second place it
puts the urea into the urine. As it cannot
store urea in any considerable amount within
its cells, the amount of urea that it can extract
from the blood becomes quickly dependent on
the amount it can put into the urine. Very
few normal kidneys can put more than 40 gm.
of urea into a liter of urine (or 4%) and the
ordinary urine output is between 1 and 2
liters a day. On ordinary diet and activity a
human being furnishes some 20 gm. of urea
for excretion per day, so the maximum is
about 3 or 4 times the normal demand, not
an enormous reserve as bodily functions go.
Many people in middle life even without
any manifest kidney disease cannot put over
20 to 25 gm. in a liter and it is an important
fact that this power to concentrate urea in
urine may weaken very rapidly under strain.
By strain I mean the demand for constant
maximum concentration over a period of days.
On the other hand, it may recuperate as rap-
idly when the strain ceases.
.It is evident that the way out of such a
difficulty is to increase the urine volume, and
this is exactly what happens in chronic ne-
phritis when large volumes of low gravity
urine are passed, the low gravity necessitating
the large volume. Any condition that leads to
continued low urine volume may easily lead
to a rapid rise of NPN. Prolonged vomiting,
so that little fluid is taken and some lost, is
a classical cause. I recall a vomiting gastric
ulcer patient with apparently normal kidneys
whose NPN was found to be 150 mg. and
dropped to normal in a week with administra-
tion of fluid by other channels.
After surgical operations postanesthetic
nausea results in small intake, and a totally
unsuspected uremia creeps in. About the
seventh day the patients look badly and by
this time it may be too late to save them. A
gall-stone patient whose blood chemistry and
urine were normal before operation was lost
in just this way.
The way to avoid these accidents is to un-
derstand the genesis of this kind of uremia,
to keep close watch of the NPN when urine
volumes are low, and to begin forcing fluids
before dangerous figures are reached. The
ways to get the fluid in are various. The
554
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
•Tilly, 1931
stomach is the best route. When nausea
blocks this, the duodenal tube may occasion-
ally be used. Four ounces of tap water every
3 hours per rectum is well tolerated by some
patients, the Murphy drip by others. If the
rectum proves intolerant, the subcutaneous
tissue may take up a lot, but is liable to get
sore from repeated clysis. In children, the
peritoneum has been much used. Venous in-
fusion is a standard method. However much
you put in, by any or all these channels, you
must realize that you do no good unless it
comes out as urine. These large amounts of
fluid may act viciously in 2 ways : first, they
may strain the heart, and secondly, they may
simply add to edema without increasing the
urine; \y2 liter of water caused edema of
the lungs in one patient, but, fortunately,
an immediate venesection saved him. Let me
urge you not to be faint-hearted in the pres-
ence of extreme uremias of this type. There
are 2 cases in my records of patients whose
NPN reached 400 and yet was reduced to
normal. As much as 8 liters of fluid in 24
hours have been given without doing harm.
Stimulating other channels of elimination is
a method doomed to failure in this condition
because no other organ can replace the kidney
in this most fundamental function of getting
rid of nitrogenous waste. The diminution of
urine through purging and sweating is apt to
do more harm by reducing urine volume than
can be compensated for by the amount of
nitrogen that is gotten rid of in the diarrhea
and the sweat. Moreover, both these proce-
dures when carried to emergency extremes ex-
haust the patient.
Blood letting is of little avail because it
cannot be repeated. With an NPJNT of 300
mg. per 100 c.c., for instance, 500 c.c. of blood
only contains 1.5 gm. of NPN; while 500 c.c.
of urine contains 5-10 gm., even if the con-
centrating power is weak. The only way then
to save these patients is by increasing urine
volume, and the one best diuretic for this pur-
pose is water in large amounts.
The second type of uremia which occurs in
chronic nephritis need not detain us long be-
cause there is so little to do for it. It re-
sults from the failing power of the kidney to
extract urea from the blood. The stimulus
that makes the kidney take urea from the
blood is the presence of urea in the blood.
As the kidney becomes less responsive this
stimulus has to be increased in order to drive
the kidney to excrete the daily accumulation.
In this way, the NPN slowly rises, often very
slowly. There is an old painter working at
the hospital whose NPN has remained be-
tween 75 and 100 for the past 5 years, with-
out causing any uremic symptoms. In his
case this stimulus is enough to drive his kid-
ney to do its work from day to day. This, how-
ever, is a dangerous situation, for as the kid-
ney loses power the NPN must keep on ris-
ing to make it do its daily work, and finally
reaches the point where the NPN accumula-
tion in the blood and body becomes toxic and
dooms the chronic nephritic to die from the
adaptation which had helped him to live. The
condition is a hopeless one because we know
of no other stimulus that will drive a worn-
out kidney to excrete enough nitrogen. We
stop the ingestion of nitrogenous food but
accomplish little because nitrogenous waste is
formed from the body tissue, as well as from
nitrogenous food, and if we give less than
about 50 gm. protein, enough of the body
protein to make up the balance will be used
as food and we only make a bad matter worse.
Reduction of protein in the food, a sufficient
urine volume, occasional blood letting and
glucose infusions, all delay the tragedy a
little, but if the uremia is high and of the
second type a fatal termination is still in-
evitable.
It is by no means easy to be sure of the
genesis of the uremia in every case and so we
always try forcing fluids if the heart will
stand it. but in a late chronic nephritis with a
failing hypertensive heart, extensive changes
in the eye grounds, an NPN of 200, and de-
veloping uremic symptoms, the outlook is
grave in spite of any treatment. Morphin
should be freely used to relieve the pathetic
suffering of these patients.
Dropsy. The normal consistency of the var-
ious tissues depends largely on the presence
in them of a certain amount of water. When
the tissues are dehydrated they become
shrunken and firm; when they contain too
much water they become swollen and soft.
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
555
When this increase in water becomes so
°reat that an incision causes the fluid to
come out in drops, the condition is called
dropsy. When dropsy occurs in the walls of
a serous cavity the fluid collects in the cavity,
sometimes in large amounts. When it oc-
curs in a mucous membrane the fluid exudes
from the mucous surface, as into the lung,
the nose or the bowel; when it occurs inside
the skull, it is often produced with sufficient
force to increase intracranial pressure and re-
strict the blood supply to the brain.
General dropsy occurs most frequently with
cardiac and renal disease but its genesis is
very complex. Fluid reaches the tissues
only through the capillary walls, while it is
drained from the tissues both through capil-
lary walls and the lymph channels. In other
words, we believe that food and oxygen are
carried from the blood stream to the tissues
as an aqueous solution which passes out
through the capillary wall, and that carbon di-
oxide and waste products, similarly dissolved
in water, pass from the tissues to the blood
stream through the capillary walls, except for
such as are exhausted through the lymph. In
other words, there are 2 streams, opposite in
direction, constantly flowing through the cap-
illary walls. We do not know whether these
streams occur alternately in the same capillary
or if some capillaries subserve the purpose of
outflow while others subserve that of intake.
We do know, however, that normal tissue
moisture results from a balance between the
volume of outflow from the blood, and the in-
flow to the blood plus the lymph flow, and that
dropsy is the result of a predominance of out-
flow over exhaust.
The factors which control this exchange of
fluid between the tissues and the vessels are
very imperfectly understood. I wish to men-
tion some of them. Salt exchange is the chief
adjuster of osmotic pressures in the body
fluids ; so, when salt accumulates in a tissue
water regularly follows it so as to prevent a
rise of osmotic pressure to a mischievous level
in the tissue concerned. Widal and his fol-
lowers believed that dropsy was caused by the
deposit of an abnormal amount of salt in
the tissues and the resulting accumulation of
enough water to adjust the osmotic pressure.
They showed patients who could be made
dropsical or normal by simply varying the
salt in the diet, and I have seen such. They
showed that extra salt caused sudden rises in
body weight and vice versa. There can be
no question that salt is an important factor
in dropsy, but it is by no means the only one.
The colloids exist in the body as jellies ;
that is, they are combined with a certain
amount of water. And the jellies which they
form may be thicker or thinner ; that is to
say, under influences which apparently do not
change the chemical structure of the colloids,
the amount of water which they can bind
varies considerably. Moreover, the colloids
do not pass through animal membranes nearly
so readily as the crystalloids. So the blood
protein tends to stay in the blood stream while
the salt may easily escape. Similarly, the tissue
colloids stay outside the blood stream. The
enthusiasts hold that blood-tissue water ex-
change depends on the amount and the water-
binding power of the colloids inside and out-
side the capillary wall, and that normally the
blood-water is kept inside the vessels by the
water-holding power of the blood 'colloids.
They regard the dropsies that occur when the
blood proteins are reduced as due to this fact.
While this whole subject is difficult, there is
a strong leaning on the part of many able in-
vestigators to regard the relation between col-
loids and water as another important fact in
water distribution within the body.
Krogh has shown that the capillary bore is
controlled by a hitherto unknown set of con-
tractile cells applied to the outside of the capil-
lary walls and under the control of a separate
set of vasomotor nerves. It is further known
that when the capillaries are dilated the out-
flow through their walls becomes greater than
the inflow ; in other words, wide capillaries
tend to “leak”, and this leakage ceases when
they again contract. So capillary dilatation is
another factor in the production of dropsy.
Hydrostatic pressure rising above normal
inside the capillaries favors an excess of out-
flow through the walls. Perhaps it does so
by causing dilation. At any rate its effect is
seen every day in the marked influence of
gravity on the site of edema.
When capillary circulation slows below the
556
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
normal limit ( stasis ) “leakage” is favored.
Perhaps it is because the capillary walls suffer
reduction of their oxygen supply.
The least understood and probably the most
important factor in controlling the water ex-
change is the life activity of the endothelial
cells which form the walls of the capillaries.
How they govern the 2 opposite currents is
as unknown as how the brain cells produce
thought. This factor, though unknown, must
never be forgotten in considering a dropsy.
When we are faced with a dropsy it is well
to bear in mind just what we wish to ac-
complish. First, we must induce a flow of
tissue fluid into the vessels greater than the
outflow from them. Then we must induce
some excretory organ to pick up this extra
water from the blood and eliminate it from
the body. Unless both these things happen
the dropsy will remain. The kidney may be
stimulated but the tissue fluid fail to move;
on the other hand, the kidney may fail to
pick up the extra water from the running
blood. It is not surprising, in view of the com-
plexity of the problem, that the most effective
treatment of dropsy is primitive and empiric
rather than rational.
We can mitigate the influence of gravity by
putting the patient to bed; wre can foster the
speed of the circulation by cardiac drugs; we
can limit the supply of dropsy, forming sub-
stances by reducing the intake of salt and
■water ; we can try to increase the blood col-
loid by infusions in gelatin or a protein-rich
diet ; we can remove some of the accumulated
fluid by puncture; but when it comes to di-
rectly influencing the flow of the dropsical
fluid back into the vessels, that is a harder
matter.
Here, as in uremia, the one important chan-
nel of escape, besides the puncture needle, is
the kidney. We see dehydration from dysen-
tery, but I have never seen a dropsy cured by
inducing a diarrhea. Free bowels help a
little but not much. Similarly, I have yet to
see a massive dropsy sweated out.
A French writer says that the edematous
patient “urinates into his tissues” ; and the
problem is to make him urinate into his blad-
der. With this purpose in view, we give drugs
which have been found by experience to in-
crease the flow of urine. Of these, the most
used are the purine group, caffein, theocin, and
especially diuretin. As we all know, they
often start a urine flow but fail to maintain
it. The stronger ones may irritate the kid-
ney. Like all diuretics, they work better in
cardiac dropsies than in those associated with
renal disease. Many of the inorganic salts
have a diuretic effect, and of these the acetate
and citrate of potash are most used. They do
not irritate, but frequently fail. Urea is
recommended as non-irritant, but it has to be
given in such large doses that the stomach
often rebels; 20 to 100 gm. per day is a good
deal to stomach, and what experience I have
had with it has not been very encouraging.
Of all diuretics there is one that stands out,
and that is mercury. It may be given by
mouth, as calomel, and I used to have success
with Guy’s pill — calomel, squill and digitalis,
1 gr. each. The new preparations, novarsurol
and salyrgan for intramuscular use, are cer-
tainly remarkable in their effects ; they surely
influence water exchange and stimulate the
kidney at the same time, but must not be used
in severe or acute renal inflammation because
they irritate in stimulating. They may cause
stomatitis or colitis, though I understand that
salyrgan very rarely produces toxic effects.
One word about puncturing dropsical legs,
as all writers stress the danger of fatal infec-
tion from this procedure. When an intern,
I hastened a death that way and consequently
for many years have watched cardionephritics
die with massive dropsies, feeling content to
let them do so without trying leg puncture.
Two years ago, persuaded bv something I had
read, I tried making a cut about j/2 in. long
in the skin on the outer side of each ankle.
The patient had a huge anasarca and had to
sit in a chair to breathe. Diuretics had failed
utterly. The incisions were made under strict
asepsis and dressings were changed with as
much ease as if the wound were into the peri-
toneum or into a joint. He drained 1 to 3
liters a day through these wounds, and after
the legs began to shrink a copious urine flow
began spontaneously and the dropsy completely
disappeared. Subsequent attempts have caused
no infection, so I have become a convert. If
you try it, remember the risk, and carry out
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
557
the strictest asepsis till the wounds are com-
pletely healed.
Hypertension. The immediate genesis of
hypertension is easier to understand than that
of dropsy, but its treatment, in general, is
less successful. Hydrostatic pressure of the
blood within the arterial tree depends on 3
varying factors : the volume that is in the tree,
volume that is being pumped in, and volume
that is escaping. The arterial tree is a reser-
voir with elastic walls and the fuller the res-
ervoir the greater the pressure exerted on the
contained blood. This reservoir has one in-
flow from the heart and many outflows
through the arterioles. The blood com-
ing in tends to distend its walls and so raise
the hydrostatic pressure of its fluid contents.
The blood that escapes allows the walls to
shrink and so lowers 'the hydrostatic pressure
of contained fluid.’ The relation of inflow to
outflow then determines the pressure. Re-
duction of inflow regularly lowers pressure ;
we see this every day in failure of the heart.
Reduction of outflow causes increase of pres-
sure.
Normally, blood supply of the various or-
gans is constantly increased or decreased, ac-
cording to their changing needs, by dilatation
and constriction of the arterioles through
which blood must reach them. Yet this con-
stant shifting is accomplished, except in con-
ditions of unusual activity, without any sig-
nificant departure from normal blood pres-
sure. If, however, the average tonus of all
the arterioles rises the total capacity of their
myriad opening's becomes less and outflow
from the tree as a whole is reduced. This re-
sults in a rise of blood pressure, and is the
predominant cause of blood pressure as we
meet it clinically.
The cause of this increase of average tonus
is not well known. One of the theories about
it is that it is a beneficial adaptation for in-
suring the necessary blood supply to vital
organs when their vessels have become nar-
row through sclerosis, and therefore no at-
tempt to reduce it should be made. The kid-
ney requires more blood in proportion to its
size than almost any other organ in the body.
When we look, after death, at a kidney whose
arteries are so sclerosed that their bore is re-
duced to perhaps normal size, and con-
sider the possibility if their dilatation is pre-
cluded, it is not hard to believe that the blood
flow to all the rest of the body must have been
restricted through arteriole contraction in or-
der to insure the kidney its proper share of
blood. In many other cases we find no such
basis at autopsy for explaining the purpose of
the increased pressure which had existed dur-
ing life. That hypertension shortens life,
chiefly through heart failure and apoplexy,
there is no question; it also limits the func-
tional power of the patient while he lives. The
higher the pressure the more trouble it makes.
When it falls, as the result of rest or any
other indirect cause, the patient is regularly
benefited. When it is reduced by direct
treatment, even over short intervals, the pa-
tients are benefited. Perhaps when we get
more potent remedies to lower it we shall find
cases with sclerosed kidney arteries in which
we may do harm by trying to reduce it too
much. In the present state of our knowledge,
however, I think we are justified in always
trying to reduce it to as near normal as we
can.
A good deal of sanity is required in hand-
ling hypertension cases. The condition is of
bad prognosis, and yet patients carry it for
years without apparent damage. I recall 2
patients, 1 still under observation, who have
had pressures well over 225 for 10 years with-
out any symptoms, without retinal changes
and without any pronounced enlargement of
the heart as seen by x-rays. So, it is bad
practice to talk too much of its dangers. Then
again it is always difficult to fail gracefully.
After telling the patient that he is fortunate
to have consulted us in time, and trying one
plan after another with no success, it is a
little awkward to say that his pressure had
better not be reduced, as it is a beneficial pro-
vision of nature in his case. I quite under-
stand the psychology of physicians who feel
that this is one of the times when it is best
for the patient not to know the full truth.
If we look dispassionately over the list of
methods for reducing blood pressure, this fact
stands out; there are many effective methods
of reducing it, but not one method that can
be thoroughly relied on to keep it down. The
558
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July. 1931
one certain way to reduce it in a crisis is vene-
section. This reduces the volume of blood in
the arterial tree and if enough blood is let the
pressure is bound to fall. The blood volume
is so quickly restored, however, that the pres-
sure often rises to its former level within 24
hours and the procedure cannot be often re-
peated. Some clinicians bleed plethoric
hypertension patients every month or so and
report benefit, but this use of the method can
hardly prove generally helpful. Rest, sweat-
ing, sedatives, arterial dilators, all help tem-
porarily, but when ordinary activities are re-
sumed the pressure is apt to come back.
When we turn to examine the question of
more prolonged effects we find that potas-
sium iodide, the reliance of the former gener-
ation. has failed to prove its effectiveness and is
no longer thought to hold the blood pressure at
a lower level than it would lie if the potassium
iodide were not taken. Chloral and aconite
work in some cases, but for a time only. Good
reports of liver extract and watermelon seed
have been recently published, but these reme-
dies are still in the experimental stage. A
mode of life which permanently removes the
strain and effort is quite effective for con-
siderable periods, but it is impossible to per-
manently reduce the strain of life enough in
most of our patients to significantly reduce
the blood pressure. There is only one method
that has worked for me and that is the salt-
free diet. Salt privation is recommended more
or less generally in dropsy, but regarded as
useless in hypertension by most competent ob-
servers. My experience with it in hyperten-
sion has been so convincing that I wish to
discuss it with you at some length, not only
in relation to hypertension hut also in regard
to dropsy and inflammation of the kidnev.
The salt-free diet was suggested by Widal
and Javal, about 1900. as a result of their
work on salt and dropsy. After trying it, the
French also believed that salt irritated an in-
flamed kidney and that it caused increase of
blood pressure, so they recommended salt
privation in these conditions also. Salt is a
threshold body ; that is, it is only taken from
the blood by the kidney and put into the urine
when its percentage in the blood rises above
a certain figure, known as the threshold point.
This threshold point is about 0.55% or about
5.5 gm. in a liter. There is reason to believe
that this threshold may move up and down.
If salt is excluded from the diet and large
quantities of water are drunk and voided, a
urine without any salt is produced, while the
salt in the blood remains at the threshold
point. So. a salt-free diet simply removes the
excess of salt ; it does not deprive the bodv
and blood of salt. Another point to remem-
ber is that salt is neither formed nor destroyed
in the body to any considerable extent, so
that the output approximately equals the in-
take and we are not faced with the difficulty
met with in uremia, where taking protein out
of the diet cannot prevent the accumulation of
nitrogen waste in the body.
Dropsy cases react very differently to the
salt ration. There are cases of massive
dropsy that will completely disappear within
a few days on salt privation and will reappear
as promptly when salt is again given. These
dropsies, in ordinary language, are due to salt
and can be cured by taking salt away. Un-
fortunately, they are the rare exceptions. A
great many dropsies can be made definitely
worse by excess of salt in the diet and can be
made a little better by salt privation. Some
severe dropsies are not at all reduced by salt
privation. We do not try to make them worse
by giving it, but there is evidence that salt may
increase the dropsy in such cases. It is,
therefore, proper to reduce the salt intake to
a minimum in every dropsy.
Salt is the basis of all good seasoning and
the salt-free diet is so insipid to some patients
that it interferes with their taking enough to
eat. When salt privation is doing no appar-
ent good and tasteless food is causing a loss
of nutrition, enough salt should be given to
make the food palatable.
In hypertension, many good observers have
tried salt privation and report that it yields no
results ; among them Munk, Lichtwitz in
Germany, Christian in Boston, and many
competent men in this city. Others have had
success with it. It is difficult to understand
these completely opposed views. As I am an
advocate and in the minority, let me state my
experiences and leave judgment to you.
There are many cases on my office records
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
559
of patients in middle life who have come with
pressures between 200 and 240, who have
been put on a salt-free diet without any medi-
cation and without any modification of their
modes of life, and who have returned to the
office in a week or two with pressures of 140
to 160. This fall in pressure has been main-
tained for many of them as long as they have
consented to follow the strict diet. I have
similar records of hospital cases, but their
rest in bed and other treatment might easily
have produced the result, and the follow-up
has been much less accurate. There is 1 case
of a school teacher who had a blood pressure
of 220 for 3 years, who was then put on a
salt-free diet and whose pressure has remain-
ed around 160 for 10 years. On occasions
she breaks over the diet restrictions and the
pressure rises, only to fall again when .the
strict diet is resumed. There are other
records of patients whose pressure has been
only slightly reduced, and there are many
records of cases in which the salt-free diet has
not reduced the pressure at all. It is my im-
pression that in nearly J4 the cases of
hypertension, as they occur in office practice,
a notable reduction can be attained by this
plan. In the advanced nephritics in the hos-
pital wards it yields much less.
There is perhaps a reason why some clini-
cians have found it futile, and that is the salt
has not been sufficiently restricted. Salt priva-
tion will 'usually not affect blood pressure until
the diet contains less than 2 gm. per day, and
in some cases not until the salt intake falls be-
low 1 gm. In hospital work, diet errors often
creep in. As the salt output approximates the
intake an excellent and easy check is to de-
termine the amount of salt in the 24 hr.
urine. Even in private practice it is surpris-
ing how often salt outputs above 2 gm. are
found in patients who intend to cooperate in
every way. I believe that many clinicians who
doubt the efficiency of the salt-free diet have
not instituted such checks. Perhaps another
reason for its disrepute is because many clini-
cians have tried it first on advanced ward
patients, and, obtaining no results, have hesi-
tated to force its discomfort on their private
patients.
The French writers believe that salt is a
kidney irritant and so avoid an excess of it in
acute renal inflammation. Many authors fol-
low this restriction, probably because edema
also is apt to occur in such cases.
My belief in the salt-free diet was deeply
rooted by the following case : A man, 30 years
old, was admitted to the hospital June 5, 1923.
He had scarlet in childhood. Had a bad sore
throat during the previous January. On
February 13, 1923, he went to bed with a little
dropsy, right hydrothorax, and obstinate
nausea and vomiting, which latter persisted
till his admission. His urine contained
some albumin. On February 18 he had
6 convulsions and was delirious. On April
24 he had 7 convulsions, and following
these his sight failed till he was totally blind
by May 5. On May 1 his NFN was 37 mg.
The family money was exhausted and he was
sent to the hospital to die.
On examination, he was emaciated, very
sick and totally blind. The eye-grounds
showed a mass of hemorrhages and patches
and the disc outlines were completely lost.
Blood pressure was 200/140. The heart was
large, with a diffuse apex beat, accentuated
second aortic, and an apical systolic murmur.
The urine contained a heavy trace of albumin
and some casts. There was no edema. He
was not anemic. NPN was 51 mg. He was
put on a salt-free diet and 2 tests of his 24 hr.
urine showed 1.9 gm. and 1.3 gm. respectively.
No other treatment, except nursing, was tried.
In a week he began to improve. By June 18 he
was out of bed. On July 21 he was discharged.
He could then read the headlines, all his other
symptoms were gone, the eye-grounds looked
remarkably better, his NPN was 39 mg., he
had gained about 20 lb. weight and his blood
pressure was 148/95. I kept track of him
until the end of 1926, when he left the city
for business reasons. He went to work Jan.
1, 1924. During the following 3 years he
worked hard and was well. His eye-grounds
healed so completely that the surprised eye
specialist, who had seen him in the hospital,
pronounced them practically normal. His
sight was normal and blood pressure remained
near 140/90. Urine continued to show a trace
of albumin and a few casts. NPN was 40
JOURNAL OF THF. MEDICAL SOCIETY OF NEW JERSEY
July, 1931
5(>0
mg. at his last visit. Weight rose to 158 lb.
He remained on a salt-poor diet.
I am sure if any one reports a similar case
treated only with watermelon seed or liver
extract it will cause quite a stir. So you must
not blame me if I remain an advocate of the
salt- free diet in certain cases of hypertension
and nephritis.
In conclusion, I ask you, then, to dis-
tinguish between 2 kinds of uremia and to
treat that which results from failing concen-
tration with large amounts of water, to try
lumbar puncture and venesection in con-
vulsions, to always think of the capillaries in
cases of dropsy, and to give the salt-free diet
a fair trial in hypertension.
CIRCULATORY DISTURBANCES IN
THE EXTREMITIES OF DIABETICS;
THEIR RECOGNITION*
David W. Kramer, M.D.,
Associate in Medicine, Jefferson Medical College,
Chief of Diabetic Clinic, Jewish Hospital,
Philadelphia, Pa.
Diabetes mellitus has been given in the past
10 years considerable thought and attention
by the medical profession. This has stimu-
lated scientific research and has resulted in
one of the best and most valuable gifts to
mankind — insulin — the pancreatic extract de-
veloped by Banting and his co-workers. With
the advent of insulin, we became privileged
to witness the solution of some of the most
difficult problems presented by diabetes: (a)
diabetic coma, always before a potent factor
in the diabetic mortality rate; (b) juvenile
diabetes, dooming its sufferer to a brief 2-3
year life span (a group now proudly, and
justly so, spoken of by Joslin as his “10 years’
club”) ; (cj surgery in diabetes. To all dia-
betics insulin has brought the boon of a
lengthened life span, we know, but what medi-
cal pitfalls may be waiting in these prolonged
years for the patient still remains to be in-
vestigated. If the continuous course of the
diabetic condition persists, what complications
♦(Presented at the Monmouth County Medical
Society meeting, January 28, 1931.)
may be expected and how may they perhaps
be averted by our vigilance?
The cardiovascular system claims first place
in any investigation of this kind. The im-
portance of giving priority to this system is
obvious ; first, the notorious influence worked
by diabetes in producing changes in the walls
of the arteries ; second, the prevalence of cor-
onary disease in diabetics ; and third, the in-
crease in complications of the extremities at-
tributable to impaired circulation, the most
important of such complications being gan-
grene.
Gangrene has long challenged medical
science, not only because it is said to be re-
sponsible for more deaths than any single
factor, but also because it has the baffling
faculty of developing while the patient is un-
der medical observation and treatment. It
seems logical, then, to direct our investigation
so as to determine whether or not this com-
plication is preventable. To accomplish this
we must first have some understanding of the
development and pathology of atheromatosis
and arteriosclerosis and their relationship to
diabetes mellitus. The next step should be
the ability to recognize early these pathologic
changes in the circulation so as to be prepared
to check further progress and prevent the sub-
sequent effects which invariably follow. Onr
problems, therefore, are: (1) how do athero-
matosis and arteriosclerosis develop and what
influence does diabetes have upon these con-
ditions; (2) what are the signs and symp-
toms of impaired circulation in the extremi-
ties.
The first problem is to determine what in-
fluences are at work in the development of
atheromatosis and arteriosclerosis, and num-
erous contributions have appeared in the litera-
ture upon this subject. Time and space do
not permit going into a detailed discussion of
these pathologic changes. Among the various
explanations offered, Aschoff's “imbibition”
theory has received most favorable comment,
The increase of lipoids, particularly choles-
terol, in the blood predisposes to changes in
the intimal ground substance. As the process
develops, the intima itself becomes involved.
Subsequently, atheromatous plaques make
their appearance. Later, chemical changes of
July, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
561
the cholesterol esters with calcium salts may
take place, resulting in the calcific deposits
seen in arteriosclerosis. Added to these in-
fluences, the hyperglycemia and acidosis in
diabetes must also be considered. Warren
mentions the “possible influence of a high
sugar concentration in producing swelling of
the intimal ground substance through changes
in osmotic pressure”. Joslin comments upon
the role played by hyperglycemia and also
acidosis in the production of atheromatosis. Is
it surprising that the diabetic individual is
prone to develop sclerotic changes in the ar-
teries? The frequency of atherosclerosis in
diabetes is now an accepted fact. It may be
demonstrated even in the young diabetic, par-
ticularly after a period of 5 years ; this phase
of the subject has been recently discussed by
Shepardson.
The next problem is early recognition of
vessels that have undergone pathologic
changes. When this is accomplished, then de-
tection of potential gangrene is possible. In-
formation can be gathered in 2 ways; (a) by
a careful history, particularly for symptoms
which may lead us to suspect impairment of
circulation, and a thorough physical examina-
tion of the extremities; fb) confirmatory tests
which may throw some light upon the condi-
tion of the arteries and capillaries.
Pathologic changes in the arteries naturally
affect the normal distribution of blood to the
extremities, resulting in trophic disturbances
and also a lowered resistance of tissues against
infection. Manifestations of disturbance in
circulation will depend upon such factors as
the type of vascular pathology, such as athero-
matosis, arteriosclerosis, thrombo-angiitis ob-
literans or embolic; the extent and duration of
the impaired circulation and the degree of suc-
cess in establishing a collateral circulation.
Regardless of the type of pathologic change
in the vessels, the method of approach in
studying these cases is practically the same.
The history should yield information as to
whether or not the patient complains of
claudication, cramps in the calves of the legs,
coldness in the feet, numbness and pains. A
history of trophic ulcers or focal gangrene
may be significant.
Examination of the extremities is exceed-
ingly important, and in a vast majority of
cases this method alone may permit diagnosis
of a definitely impaired circulation. The fol-
lowing signs should be observed : pallor when
the feet are in the reclining position, and par-
ticularly so if it exists when the feet are in
the dependent posture ; rubor and cyanosis,
when the feet are dependent should likewise
be observed ; diminution or absence of the
dorsalis pedis pulsation ; sclerosis of the dor-
salis pedis artery ; coldness of the parts and
a variety of lesions which will be discussed
subsequently. These lesions were described
in detail in a previous publication as “early
or warning signs of impending grangrene”.
Briefly, they include rose spots, scars, pig-
mented areas, blebs, ulcerations and small
areas of focal gangrene. The rose spots are
small, pink, or erythematous, areas usually
seen on the legs and sometimes on the feet ;
they are not numerous, and are not unlike the
rose spot seen in typhoid fever. They are pre-
sumably due to some pathologic changes in the
minute vessels and seem to indicate recent ac-
tivity. They may last for weeks. Ultimately,
they change to pigmented areas and in time
are replaced by small scars. Scars are fre-
quently seen on the legs in these cases of im-
paired circulation. The large oval or elliptic
scars are often attributed to injuries or
bruises. This may be so but it is question-
able whether all of these scars may be so ex-
plained. Not infrequently patients are unable
to say exactly when or how they were bruised
and there may be scars over the soft parts
which do not bruise so easily. They may be
the expression of insidious atrophic changes
of the tissues supplied by small vessels which
are slowly but progressively undergoing oc-
clusion. There are smaller scars which merit
some consideration ; they have a punched-out
appearance and look like the pock marks of
smallpox ; they are not numerous and are
usually seen over the legs and sometimes on
the dorsum of the foot ; they may be later
developments of the rose spots mentioned
above.
Bullas may be found on the toes or on the
feet. On one occasion they were observed on
the fingers. They vary in size from 1 to 3
cm., usually develop over night and may
562
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
have been preceded bv a burning sensation.
As a rule, the)' are painless, not surrounded
by an inflammatory area, and have a tendency
to become purple in color and be followed by
local gangrene. These blebs are most likely
due to a recent and more or less rapid occlu-
sion of the smaller vessels. They are not com-
monly found but when they do exist, are
highly significant and may be looked upon as
forerunners of gangrene. This fact has been
observed in practically every case where the
bul las were seen.
Other lesions, such as ulcerations, infec-
tions on a small scale, trophic disturbances
and focal gangrene need not be discussed ; they
should be recognized without difficulty even
in hasty examinations.
Various laboratory methods have been sug-
gested for studying the condition of the ar-
teries and capillaries. It is true that a care-
ful observer may be able to recognize patho-
logic changes in the vessels by a thorough ex-
amination. This may apply to well developed
conditions. However, in patients who do not
present sufficient symptoms and signs, the
laboratory may help greatly in confirming or
detecting evidences of impaired circulation.
Among the tests may be mentioned : ( 1 )
calorimetric studies, including skin tempera-
ture readings and heat loss in the extremities ;
(2) the oscillometer; (3) skin reactions to
histamin; (4) Roentgen rays; (5) intrader-
mal wheal test; (6) intraarterial injection of
opaque solutions followed immediately by
roentgenography; (7) capillary microscopy.
It is not my intention to discuss the technic of
these measures in this presentation. Studies
of the extremities and an attempt to evaluate
the different methods are being carried out
and will be published in the near future, but
I will briefly mention some of the benefits
which may be expected from the more prac-
tical tests such as the oscillometer, the his-
tamin test, skin temperature and Roentgen
rays.
The oscillometer, modified by Pachon, is an
instrument based on the principles of the
sphygmomanometer. Readings of the thigh,
leg and foot will give us some idea as to the
condition of the larger vessels. Zero readings
of the thigh and legs are significant and in-
dicate that there is a dimunition of the circu-
lation. and particularly point to the larger
vessels. Zero readings need not indicate that
gangrene exists.
Skin reactions to histamin have been
studied bv Lewis, and its clinical application,
particularlv in diabetes, has been discussed by
Starr. Bv studying the wheal formation and
local erythematous reaction of the skin fol-
lowing the inoculation of histamin acid phos-
phate, one may gather facts concerning the
condition of the capillaries and the smaller
vessels in the extremities.
Of the calorimetric studies, the skin or sur-
face temperature test is the most feasible.
Some interesting contributions by Brown,
Allen and Mahorner, and by Scott, indicate
that this method of study is reliable. It not
only informs us as to the condition of the
vasomotor system in the region studied but
may also throw some light upon the condition
of the larger arteries.
Roentgen rays are helpful by revealing cal-
cific changes in the larger arteries. This in-
formation, unfortunately, is limited and may
give a false impression of the exact state of
affairs. Despite sclerotic changes in the main
arterial branches, it is quite possible that a
sufficient collateral circulation has been estab-
lished; thereby maintaining a fairly satisfac-
tory state of nutrition of the parts.
The methods of study described above may
all have their limitations. One need not rely
solely on any single test. When employed
with the idea of confirming suspicions of im-
paired circulation, after a thorough and com-
plete examination, they undoubtedly will prove
their usefulness. If used routinely, in some
cases they will point out deficiency in blood
supply where the impaired circulation might
have been overlooked.
The discussion thus far has been more or
less limited to the understanding and recog-
nition of impaired circulation. A word now
concerning other disturbances of the extremi-
ties in diabetes, among which may be men-
tioned phlebitis, infection and gangrene.
Phlebitis has received little consideration.
Thrombophlebitis does occur but it is doubtful
whether the incidence is any higher than in
nondiabetics.
July, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Infection is included in the discussion of
circulatory disturbances for 2 reasons : first,
because of the well known fact that im-
paired circulation lowers resistance of the tis-
sues supplied by the damaged vessels ; and
second, because infection often precedes the
development of gangrene. Another fact worth
mentioning is that infection may be deep seat-
ed and easily overlooked. This applies particu-
larly to the feet. It is not uncommon to find a
deep cellulitis in the foot either independent of
or associated with osteomyelitis of one of the
metatarsals. This type of infection almost in-
variably is followed by a local gangrenous
process, or gangrene of one or more toes may
appear.
Gangrene is easily recognized by examin-
ation of the extremities. Various forms of
gangrene may be observed, such as the ar-
teriosclerotic type, thrombo-angiitis obliterans,
obliterative endarteritis, embolic and the so-
called “diabetic gangrene”. Since the topic
■of this presentation concerns itself chiefly
with the understanding and recognition of
circulatory disturbances of the extremities, a
discussion of the different types of gangrene
is intentionally avoided. Detailed descriptions
and differential diagnoses may be found in
any text-book on gangrene or diseases of the
circulatory system.
Gangrene usually appears late in the course
of diabetes. It is the end-result of changes
in the walls of the arteries. Individuals past
middle age and who have had diabetes for 5
years or more are liable to develop this com-
plication. Infection, either local or deep
seated, may produce gangrene in any stage of
the disease. Since gangrene is a later develop-
ment of vascular changes, is it not possible to
prevent it? This can only be accomplished by
the early detection of vascular changes and
impaired circulation by the various methods
of study described above. After recognition
of the underlying pathology, measures should
be taken to correct the diet, having in mind
not only the hyperglycemia but the lipoids and
the cholesterol content as well. It is exceed-
ingly important to control the diabetic condi-
tion. Other preventive measures may be
directed toward improvement of the condition
of the vessels by systematic foot exercises and
563
diathermy. Incidentally, these patients should
be warned that they are potential cases of
gangrene, that the utmost care should be given
to the feet, that trauma and infections are to
be guarded against, and that only the fullest
cooperation may ward off the most dreaded of
all complications, gangrene.
COMMON DISEASES OF THE ORAL
MUCOSA*
Bart M. James, M.D.,
Newark and Montclair, N. J.
A routine examination of the oral cavity
for abnormalities should be made as a part of
every physical examination in any branch of
medicine. This applies particularly to the
specialty of dermatology and syphilology. Our
predecessors in medicine recognized - the value
of close observation of the tongue and gained
many helpful ideas from that part of their
examination.
Diseases of the skin are often preceded by
or associated with definite clinical evidence of
the same pathologic entity within the oral and
nasal mucosa. This relationship can be ex-
plained by the fact that the skin and the
mucous membrane of the nose and the mouth
is derived from a common embryologic source
— the ectoderm. Also some diseases affecting
the general constitution very frequently have
their prodromal symptoms within the oral
cavity. This is evidenced by the Koplik spots
of measles, the pharyngeal congestion of scar-
let fever, and the ulcerations of agranulocytic
angina. The appearance of a few discrete
miliary tubercles may lie the first clinical
evidence of tuberculosis and a persistent but
mild stomatitis associated with burning of the
tongue may antedate the blood picture of per-
nicious anemia. Certain oral lesions may oc-
cur as part of the menstrual cycle and preg-
nancy. Vicarious bleeding from the gums with
submucous hemorrhages, aphthous stoma-
titis, herpes, salivation and toothache, may ap-
pear coincident with the menstrual period.
*(Read before the Middlesex Dental Society, New
Brunswick, N. J., November 1930.)
564
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
Gingivitis and alterations in the teeth are seen
at times in pregnancy. Urticaria, angio-
neurotic edema and purpura may involve the
mucous membrane of the nose and mouth.
The usually fatal disease, pemphigus, may be-
gin in the mouth in the form of bullas which
quickly change to erosions and ulcerations ;
diagnosis would be influenced by age of the
patient, subsequent skin eruption and the
gradual deterioration in health.
The diagnosis of certain diseases of the
skin is often facilitated or proved by examin-
ation of the mouth for similar lesions; modi-
fied in the mouth in appearance and structure
because of the moisture and resulting macera-
tion. Irritation from the teeth and from food
alter the appearance of lesions, and very fre-
quently secondary infection occurs. The sur-
face of papules may be covered with a mem-
brane, and vesicles and bullas are usually seen
as simple erosions. However, there are cer-
tain oral conditions the appearance of which
may be sufficient to make a diagnosis; for in-
stance, certain benign and some of the malig-
nant tumors. Grouping and distribution of
lesions in the mouth are less distinctive than
on the skin and a complete examination of
the entire skin may be necessarv in order to
find an eruption associated with the lesions in
the mouth. The oral lesions of lichen planus
are often mistaken for leukoplakia but if the
characteristic flat-topped, shiny, violaceous
papules are present on the skin, for example,
of the fore-arms and glans penis, the diag-
nosis is complete. The mucous patches of
secondary syphilis may be confused with
aphthous stomatitis, erythema multiforme and
other local affections but they can be differ-
entiated by an examination of the entire skin.
Oral lesions produced by the ingestion of
drugs are usually difficult to diagnose unless
concomitant skin lesions are present or a his-
tory is obtained of taking the suspected drugs.
There are some drugs which have a pre-
dilection for the oral cavity as a site of erup-
tion, such as the antisyphilitics (mercury, bis-
muth, arsphenamin), the barbital group (in-
cluding veronal and luminal), the antipyretics
(antipyrin, acetanilid, phenacetin and pvram-
idon), the salicylates and the phenolphthalein
compounds. Poor dental hygiene, complicated
by bacterial infection, plays a predominating
part in the production of a stomatitis.
Mercury. Stomatitis due to mercury begins
usually with edema and intense lividity of the
gums in conjunction wiith excessive flow of
saliva and pain on closing the jaws. This may
continue until the tongue, tonsils, soft palate
and pharynx are affected, with formation of
a necrotic membrane. Toleration to mercury
can be increased by rigid dental hygiene.
Arsphenamin. Stomatitis caused by arsphen-
amin may be due to an idiosyncrasy rather
than an overdosage. It may or may not occur
in conjunction with a dermatitis. The lips,
tongue and buccal mucosa are dry, hot and
red. in contradistinction to stomatitis due to
mercury. There is usually a decreased flow
of saliva.
Bismuth. Thirty to 40% of patients had
stomatitis from bismuth in the first year of
its use. It is not as prevalent as formerly,
because of decreased dosage and longer inter-
vals between treatments. It is usually charac-
terized by bluish or bluish black pigmentary
deposits along the free border of the gingiva
and which spread until the entire gun is in-
volved; and stomatitis similar to that caused
by mercury occurs if the drug is continued.
1 he pigmentation remains for months and will
reappear rapidly if the drug is again used.
Antipyrin group. This includes antipyrin,
acetanilid, phenacetin, pyramidon and oth-
ers. These drugs are very prone to cause an
eruption of the buccal membranes and the
genitalia. The eruption may vary from a
simple congestion of the pharynx and edema
of the lips to the formation of vesicles and
bullas followed by erosions and deep ulcera-
tions. In patients addicted to the use of
acetanilid a pronounced cyanosis of the lips
and the buccal mucosa is caused by the pro-
duction of methemoglobin.
Barbital group. The lesions in the oral cav-
ity vary from a mild redness and edema to
the formation of vesicles and bullas with con-
sequent ulcerations and erosions. Lesions pro-
duced by this group cannot be distinguished
clinically from those produced by the antipy-
rin and phenolphthalein groups.
Salicylates. May cause a vesicular or bul-
July, 19 31
565
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
lous eruption of the oral mucosa and the lips,
and at the same time erosive lesions of the
glans penis may occur. Shelmire mentions
the occurrence of extensive ulcerations of the
tongue and soft palate following intravenous
injection of sodium salicylate for the tieat-
ment of rheumatism. In another case re-
ported by him vesiculation and erosion of the
lower lip occurred following intravenous use
of salicylates.
Phenol 'phthalein. Eruptions of the mouth,
lips and the genitalia are frequently observed
following ingestion of phenolphthalein as a
laxative ; usually seen on the lips in the form
of vesicles with varying amounts of edema of
the parts. Ruptured vesicles in the form of
erosions and ulcerations may be present on
the tongue and other parts of the oral cavity.
At the same time there may be an erythema-
tous, urticarial or bullous eruption of the skin
which results in various sized violaceous, pig-
mentary plaques, d his pigmentation may last
for some time and will show acute exacerba-
tions following the second ingestion of the
drug. However, some cases may show a
period, the so-called refractive period, dur-
ing which the idiosyncrasy to the drug has
diminished or entirely disappeared.
Ulceromembranous stomatitis. Vincent’s an-
gina has been more prevalent since the World
War. Foerster predicted that Vincent’s dis-
ease would be an important factor in the dif-
ferential diagnosis of lesions of the mouth
after return of the troops. McKenstry called
attention to an increase in number of these
cases in England and Canada among former
troops and civilians, and history of trench
mouth while in the army can be obtained from
some of the patients. Vincents disease must
be differentiated from stomatitis due to mer-
cury. diphtheria, and mucous patches of syph-
ilis. It may occur on the tonsil, as a super-
ficial or deep ulceration partially covered with a
dirty gray membrane, with some enlargement
of neighboring lymph-glands ; on the ramus
of the lower jaw posterior to the last molar
tooth, as a localized abscess; as a general
mouth infection involving the entire mucosa,
pharynx and tongue ; or it may be confined to
the gums where it often has its primary
source and may be confused with pyorrhea
alveolaris. Vincent’s disease may also pio-
duce an ulceration of the vulva, a conjunc-
tivitis, or an ulcerating balanitis, lhomas and
Klapproth recently reported a case of Vin-
cent’s infection of the ear following the bite
of a human, and they had previously reported
2 cases following bites of humans with
infection on the fingers. In all cases the
characteristic odor, membrane formation, and
sloughing was present. The spirillum of
Vincent and the fusiform bacillus can be
demonstrated by smears or by dark-field
preparations.
Arsenic, in the form of Fowler’s solution
in glvcerite of tannin, applied locally, has-
been used with benefit in some cases. Arsphen-
arnin and neo-arsphenamin locally and intra-
venously has been the treatment of choice foi
many years. Applications of 2% chromic acid
and paste of sodium perborate have been used
with success. Bismuth intramuscularly may
be of benefit.
Aphthous stomatitis. Aphthous stomatitis is
an acute inflammatory affection occurring
mostly in children. It may be part of a gas-
trointestinal upset or due to faulty dental
hygiene. Small vesicles with an inflammatory
areola appear on the gums, the inner sur-
face of the lower lip or the buccal mucosa,
which soon become shallow ulcers covered
with superficial gray exudate, and they are
sensitive and painful. Applications of 10 °/o
silver nitrate, with a mouth wash of potassium
chlorate or boric acid, are usually sufficient to
heal the ulcers. Existing gastrointestinal dis-
turbances usually require treatment.
Superficial and deep yeast infections. Yeast
organisms are found normally in scrapings
from the mouth and are therefore of little sig-
nificance unless obtained after the areas in-
volved have been cleansed, dried and painted
with tincture of iodin, and bits of the mem-
brane removed for microscopic examination and
culture. The most common superficial yeast
infections are thrush, macroglossia and mac-
rochilia mycotica caused by the monilia or-
ganisms.
Thrush or white mouth is usually seen in
nursing infants and consists clinically of
a superficial stomatitis and gingivitis ; usually
566
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
confined to the oral cavity, particularly the
cheeks, hard palate and margins of the tongue,
but may spread to the skin of the child and
the nipples of the nursing mother. It is caused
by the oidium albicans which is carried to the
infant’s mouth through the medium of the
mother’s breasts or of feeding utensils. There
are usually not any clinical changes in the sur-
rounding mucous membrane. Diagnosis is
readily made by appearance of the lesions
and microscopic examination of a bit of the
membrane which has been macerated in 20%
sodium hydroxide. The infection readily
yields to swabbing of the lesions with boric
acid solution, followed by application of 1%
gentian violet or 2% ferric chloride solution.
Perleche is seen at the oral commissures in
the form of whitish opaque patenes which
have a mother-of-pearl tinge. Small trans-
verse fissures appear later, showing a redden-
ed base when the lip is stretched. It is con-
tagious and is frequently seen in epidemic
form. In adults, the upper lip droops at the
angles of the mouth in such way as to form
an intertriginous area, an exaggeration of
the normal fold. Finnerud has recently re-
ported a series of 100 cases of perleche which
he found to be mycotic in origin. Perleche
simulates the split or hypertrophic, syphilitic
papule seen in the same location, or it may
be confused with the late ulcerating lesions of
syphilis. It :s best treated by application of
10% silver nitrate solution.
Macroglossia mycotica. Castellani and oth-
ers have reported cases in which the tongue
was greatly enlarged, occasionally painful, and
presenting various sized, elevated, white
plaques which resembled a beginning leuko-
plakia. Various types of the yeast organism
were isolated from these cases. The infection
may invade other parts of the oral cavity, as
in the cases reported by Shelmire; 2 cases in
which the buccal mucosa, entire gums, palate
and the Vermillion borders of the lips, were
covered with hypertrophic whitish growth, and
he compared the appearance to a diffuse map-
like leukoplakia. Cultures from the membrane
revealed a pure monilia, and his cases proved
extremely recalcitrant to various therapeutic
measures. Cauterization healed the involved
areas temporarily. Iodides by mouth and
Lugol’s solution intravenously were of tem-
porary benefit.
Actinomycosis usually begins through the
medium of a carious tooth or an abrasion of
the gum. Pea to egg sized nodules appear first
on the cheeks or tongue ; later break down, and
yellow granules or ray fungus can usually be
easily demonstrated from the discharge.
Blastomycosis is a distinct raritv. Shelmire.
in 1928, reported a case of blastomycosis in
the oral cavity. The lesion was confined to
the lower gum and consisted of a sharply de-
fined verrucous mass which filled the lower
labial vestibule. Several sinuses exuding pus
extended down into the tumor. The histo-
logic diagnosis was a granuloma of unknown
origin. Blastomyces were demonstrated by
smear and culture. Extensive ulceration of
the lower jaw followed, with multiple sinuses
opening on the cheek, chin and neck. Death
occurred within a few months.
Sporotrichosis may involve the mucous
membrane of the mouth and form abscesses
with severe ulceration. It must be differen-
tiated from syphilis and tuberculosis.
7 itmors. Almost every benign tumor of the
human body may have its counterpart within
the oral cavity, such as tumors of the vascular
system, fibromas, lipomas, neuromas, muscle
tumors and dermoids. Tumors derived from
the dental system, such as adamantinomas,
epulides, odontomas and various cysts may be
found solely in the oral cavity.
Angioma is a rather frequent tumor of the
oral cavity and is usually situated on the lips,
buccal mucosa and tongue. Angiomas con-
sist of the embryonic type of tissue in con-
tradistinction to the fixed or adult type seen
in nevus flammeus, which explains their
marked response to radium. They usually re-
main stationary in size, while lymphangiomas,
which may be differentiated bv the various
sized vesicles filled with lymph, usually have
a tendency to continual extension and enlarge-
ment. A capillary nevus, or nevus flammeus,
of the face may extend into the mouth, in-
vading the inner surface of the cheeks, gums
and palate. Venous nevi occur usually on the
anterior portion of the tongue; their color is
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
567
bluish and the size of the tumor can be tem-
porarily reduced by pressure. Simple telangi-
ectasis may occur anywhere in the mouth.
Simple varices may be seen under the anterior
portion of the tongue ; and the blood blister of
the lip in the aged.
Angiomas yield to various therapeutic meas-
ures, such as radium, coagulation, carbon
dioxide snow or excision. The method of
choice depends on location and size of the
tumor.
Papilloma. This benign tumor is frequently
seen on the dorsum of the tongue, the gums
and lips. It may vary in size from that of a
match head to that of a pea; is elevated, and
usually has a verrucous surface. Distinction
must be made from a malignancy. It can be
snared off with a cutting current and a
microscopic examination made.
Mucous retention cysts. Cysts of this type
are seen frequently on the lower lip and may
be the result of trauma. They vary in size
from that of a pin-head to that of a hazel
nut; are pale, translucent and contain a clear
viscid substance. Recurrence after excision
is usual. Desiccation is the best means of
permanently curing the condition.
Carcinoma is often engrafted on a long
standing process such as gumma, leukoplakia
or fissures. Jagged teeth, irritation from ex-
cessive cigar or pipe smoking and chewing, or
senile and seborrheic keratoses of the lips
may be the offenders ; more common in males ;
may begin anywhere in the mouth but the
lower lip. tongue and buccal mucosa are the
areas most frequently attacked. On the lips
and within the oral cavity the squamous or
prickle cell carcinoma is the type invariably
found. Basal cell epithelioma of the lip is
usually an extension from the adjacent
cutaneous surface and is seldom encountered.
Early recognition of a malignancy of the
oral cavity is of paramount importance since
metastasis occurs early because of the abun-
dant blood and lymph supply. Carcinoma
may commence as a papillomatous eleva-
tion which later infiltrates the surrounding
mucosa and ulcerates, or it may develop from
a fissure, and palpation will reveal an infiltra-
tion in the surrounding mucosa. In its in-
cipiency the diagnosis may be difficult. Eatly
biopsy, which is best accomplished by the cut-
ting- current, should be done and the section
o
examined microscopically. A positive Was-
sermann should be kept in mind. Tuber-
culosis and actinomycosis must be ruled out.
Superficial, localized carcinoma of the lip
responds favorably to radiotherapy. The les-
ion may be destroyed by electrothermic meth-
ods followed by use of radium plaques not
only to the destroyed areas but the surround-
ing tissue. If the lesion shows an area of
infiltration, gold radon seeds should be plant-
ed deeplv, in conjunction with the surface ap-
plication. Carcinoma arising from a leuko-
plakia of the lip is best treated by a wide re-
moval of the involved area with the cutting-
current, followed by the use of radium.
Tongue lesions may be treated by excision
with the high frequency knife followed by
radon implantations or by interstitial irradia-
tion with gold radon seeds implanted perman-
ently in the tumor area and also across the
base of the tongue in order to block the drain-
ing lymphatics. Prophylactic exposures of
filtered Roentgen rays should always be given
to the lymphatics draining the lips and the
oral cavity.
IAchen planus occurs in the oral cavity in
approximately 50% of cases associated with
the typical skin lesions. Lichen planus also
appears on the vaginal or urethral mucosa and
the glans penis and if there are lesions in the
above locations in association with the oral
lesions a diagnosis of syphilis might be sug-
gested. Therefore, an understanding of the
clinical appearance of the oral lesions is of
importance to rule out leukoplakia and syph-
ilis, which are the conditions most often con-
fused with lichen planus. The most frequent
site of the eruption is the posterior surface
of the buccal mucosa, usually along the line
of the closed teeth. A few gray, miliary
papules only may be present but the typical
and the usual eruption seen consists of an
irregularly outlined network of fine white
lines. The older the process, the more do the
papules coalesce and form circulate plaques
which resemble mucosa to which silver ni-
trate has been applied. The lesions seen on
668
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
the dorsum of the tongue are usually in the
form of oval plaques or stripe-like plaques.
On the margins, solitary papules may be pres-
ent. The oral lesions of lichen planus do not
degenerate, erode or ulcerate, nor are they
followed by malignant changes.
Lichen planus simulates the mucous patches
of syphilis and leukoplakia and, to complicate
the diagnosis further, it responds to anti-
luetic remedies. Fordyce said: “Leukokera-
tosis in patients who are not smokers, and
with a negative luetic history, should suggest
the probability of lichen planus and further
evidence of that affection sought for.”
Leukoplakia is the most common of the
oral keratoses and is often part of an old
luetic process. However, there are some cases
based on excessive smoking, irritation front
rough and carious teeth, alcohol and highly
spiced foods. The condition is seen more
frequently in males. The most frequent lo-
cations are the lips, anterior portion of the
tongue and the anterior portion of the buccal
mucosa just within the oral commissures in the
form of a triangle. Its recognition is import-
ant owing to its tendency to degenerate into a
squamous celled carcinoma. The proportion of
leukoplakias which result in carcinoma has
been variously estimated from .20 to 50%. It
is not always possible to say from observation
whether or not a leukoplakia is based on a
syphilitic condition, unless there is an associat-
ed glossitis and smooth atrophy. The mucosa
primarily assumes a blanched grayish or
whitish tint with effacement of the papillas
and furrows. The areas involved may grad-
ually merge, forming a thick white plaque
which is densely adherent and cannot be re-
moved by scraping. These plaques may be
fissured or more rarely present a verrucous
appearance. There are no subjective symp-
toms, as a rule, except a feeling of dryness
and roughness, unless fissures are present to
cause pain. Squamous celled carcinoma may
arise from a leukoplakia.
Treatment of leukoplakia consists of rigid
and constant oral hygiene and the removal of
irritating foods. The use of tobacco and al-
cohol is interdicted. If syphilis is the cause,
the patient should secure injections of mer-
cury, bismuth and iodides. Caution should
be employed with the use of arsphenamin be-
cause arsenic causes epithelial proliferation
and may be the provocative factor in the be-
ginning of a carcinoma. In cases which do not
respond to the above measures, and where the
process is extending, the entire area should
be destroyed by electrocoagulation.
Tuberculosis of the oral cavity or lips is
usually secondary to tuberculosis of the vis-
cera or lupus of the skin. It is most com-
monly seen on the free border of the lips, the
tip and border of the tongue, and the soft
palate. Small, yellowish nodules appear,
ranging in size from a pin-head to a lentil.
Superficial or deep ulcers may result, sensitive
to pressure and painful on talking or eating.
The ulcers are round or linear in outline, their
border is abrupt and often undermined, and
the floor is covered with a loose yellowish
crust. The surrounding area is not indurated
nor inflamed but tubercles may be seen which
have not reached the stage of ulceration. On
the dorsum of the tongue a linear or fissured
ulcer is the most characteristic form of lesion.
The process is usually prolonged for weeks
or months, with some attempt at and signs of
healing. Syphilis and epithelioma must be
differentiated by means of the microscope and
other laboratory examinations. Radium ther-
apy or destruction of the lesions by electro-
coagulation will usually cure the condition
provided there are no active foci in the lungs
or elsewhere.
Lupus erythematosus attacks the mucous
membrane in about 25 % of cases showing
cutaneous involvement. The lips, buccal
mucosa and soft palate are the areas most
frequently invaded. In the early stages, the
involved mucosa is intensively red, inflamed
and edematous, and differentiation from other
acute inflammatory processes cannot be made
unless cutaneous manifestations of the dis-
ease are present. Later, the center of the
lesions becomes depressed, eroded and the sur-
face is covered with adherent yellowish mem-
brane. The inflammation gradually subsides
and is replaced by scarring and atrophy. In
addition to erosion, the lips may be covered
with adherent dry scales. The oral lesions of
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
569
lupus erythematosus do not respond to in-
travenous gold therapy as readily as do the
cutaneous lesions. The beta rays of radium,
the actual cautery, and desiccation can be used
with good results.
Syphilis may attack the oral mucous mem-
brane without any other visible evidence of
the disease. Chancre of the lip should be sus-
pected in any indurated lesion which has sub-
maxillary or submental glandular enlarge-
ment. Chancre of the tonsil is difficult to
diagnose and differentiate from Vincent’s dis-
ease unless other concomitant symptoms are
present. Mucous patches which are analogous
to the macular and papular skin eruption
changed by moisture and maceration vary in
form from a distinct redness to definite
erosions and ulcerations. They are seen most
frequently on the tongue, gums and soft pal-
ate. The ulcerations are usually covered with
a thin diphtheroid membrane and may be con-
fused with the conditions enumerated pre-
viously.
General examination of the skin will dif-
ferentiate a great many of these conditions;
in conjunction with appropriate laboratory ex-
aminations. Darkfield examination should be
done but caution must be exercised in order
to not confuse the Spirocheta pallida with
Spirocheta microdentium and refringens.
However, an interstitial glossitis, with a
leukoplakia and a smooth atrophy of the
tongue, is diagnostic of syphilis. The sharply
defined, punched out ulcerations of the hard
and soft palate, which produce perforations of
these parts, can be clinically ascribed to syph-
ilis, although some of these are due to tuber-
culosis and to Vincent’s infection.
The presence of infiltrated ulcerations and
fissures in the lips and around the oral com-
missures of emaciated infants is symptom-
atic of congenital syphilis. These fissures
frequently result in linear scars or rhag-
ades which are seen in older children, and are
usually associated with other signs of syph-
ilis such as a saddle nose, keratitis, perfora-
tion of the hard and the soft palate, glos-
sitis and changes in the teeth. The alterations
in the teeth are caused by nutritional disturb-
ances from intra-uterine infection of the
fetus, not to a direct action of the spirochetes
on the tooth.
Lingua geographica. Erythema migrans, or
the so-called wandering rash of the tongue, is
of interest because of its clinical appearance
and unknown etiology. It appears on any
portion of the tongue as sharply defined, oval,
red areas with a yellowish gray, slightly ele-
vated border, which spreads peripherally
forming red patches. The appearance and
location change from day to day. It does not
cause anv symptoms and most patients are
unaware of its presence. X-ray therapy has
been of benefit in some cases.
Moellers glossitis may be confused with
lingua geographica. It occurs mostly in
middle-aged women of neurotic tempera-
ment. The tip, edges and dorsum of the
tongue are the parts most commonly af-
fected but at times the inside of the lips,
cheeks, hard and soft palate is involved. The
patient complains of severe pain made worse
by eating. Examination discloses sharply de-
fined patches, intensely red in color, in
which the filiform papillas are thinned or
absent and the surface epithelium denuded.
The condition is recalcitrant to treatment. Re-
moval of infected teeth and treatment of in-
fected gums should be done routinely.
Scrotal tongue. Lingua plicata is usually a
congenital and often a familial anomaly. The
mucous membrane of the tongue is plicated
and resembles the scrotum in appearance. The
condition is permanent and does not cause any
subjective symptoms. Detritus may accumu-
late in the deeper fissures and result in irri-
tation, consequently the tongue should be kept
clean with an alkaline mouth wash.
Herpes of the lips is seen frequently, while
herpes of the oral cavity is rare ; that of the
lips is prone to recur. The characteristic
grouped cluster of clear vesicles on an ery-
thematous base follow varying degrees of pain
and burning. The vesicles soon rupture and
the eroded areas may be confused with mucous
patches. Herpes is seen frequently in asso-
ciation with certain general infections, such as
malaria, cerebrospinal meningitis and pneu-
monia. Some cases may be caused by infec-
tion within the oral cavity, such as infected
570
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
teeth, tonsils and sinuses. The contents of
herpetic vesicles have been inoculated on the
scarified cornea of the rabbit, following which
an encephalitis developed similar to encephali-
tis lethargica. X-ray therapy has been of
benefit in the cases which recur in the same
location. Arsenic has been used with some
success. Other cases have been benefited by
vaccination with smallpox virus.
Eczema may attack the lips primarily or
secondarily from the skin. Varying degrees
of redness, scaling, crusting and Assuring may
be present. The circumoral eczema seen in
children is caused by the habit of moistening
the lips and adjacent skin with the tongue, in
conjunction with exposure to cold and wind.
Tooth pastes, cosmetics and mouth washes
may cause an orbicular eczema in a susceptible
individual. The cause should be ascertained,
if possible, and a protective salve such as Las-
sar’s paste used. Fissures may be touched
witih 10 c/o silver nitrate. In obstinate cases
fractional weekly doses of x-rays are indi-
cated.
Among other, but far less common condi-
tions of the buccal mucosa, should be listed
leprosy, mycosis fungoides, the lymphogranu-
lomas, Kaposi’s sarcoma, foot-and-mouth dis-
ease, pellagra, rhinoscleroma and lead poison-
ing.
DIABETES MELLITUS AND THROMBO-
ANGIITIS OBLITERANS IN THE
SAME PATIENT
Harold S. Davidson, M.D., F.A.C.P..
Atlantic City, N. J.
The association of diabetes mellitus and
thrombo-angiitis obliterans has been noted be-
fore in the literature. (Adams S.F.. Med.
Clin., N. A., Vol. 14, No. 3.) The associa-
tion of these 2 definite pathologic entities has
a very serious significance for any patient be-
cause of the difficulties encountered in at-
tempting to heal a pedal lesion. In this patient,
a spot of gangrene did develop on the foot
and only after prolonged and persistent ef-
fort was it not only kept from spreading but
made to heal. The lesion appeared on the
sole of the right foot. Determinations of the
pulse of the feet and legs showed that the
lesion was on the best foot. The circulation
was decidedly worse in the left leg and, in all
probability, had this gangrenous spot de-
veloped on the left leg it would never have
been arrested. I believe the prognosis is now-
good because of the progress made so far,
and certainly every precaution will now be
observed to allow no further trauma to occur
to either extremity.
This patient, J. P>., white, aged 65, was ad-
mitted to the Atlantic City Hospital on De-
cember 28, 1930. His father died at 93 years
of age from senility, and his mother at the
age of 49 years from heart trouble. He had
2 brothers, both of whom were diabetics ; 1
is dead and the other living.
The patient had measles and diphtheria in
childhood and rheumatism 44 years ago. He
stated that he was well until 15 years ago,
when he developed a diverticulitis for which
he was rushed to a New York Hospital for an
emergency laparotomy, and as a consequence
developed peritonitis, fecal fistula and second-
ary operations covering many weeks. It was at
the time of his entrance into this hospital that
his diabetes was discovered. When he was
ready to get out of bed. following this, he
developed phlebitis in his left leg, which kept
him hospitalized for many more weeks. The
phlebitis finally cleared up. However, for a
long time before this he had what w?as called
“fallen arches” with tiredness in his feet and
legs after walking short distances. Arch sup-
ports and other appliances were made without
relief.
After recovery from his operation and
phlebitis, he found that after walking about 1
city block he would have cramp-like pains in
the calves of his legs, so bad that he would
have to stop and rest. He now can only walk-
half a block before he must stop. Ever since,
he has had intermittent claudication.
All his adult life he has been a heavy
smoker. At the time of his operation he
smoked about 15 cigars a day. At that time he
consulted Dr. Leo Berger, of New York, who
advised cutting down his smoking, graduated
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
571
exercises, etc. Since then he limits himself
to 3 cigars a day.
He had been on a moderately strict diet,
with some lapses, having very infrequent
blood sugar determinations made. He never
was given insulin. Examines his own urine.
A week before being seen by me he attempted
to shave callus from the sole of his right foot,
and later a dark spot appeared which was
painful to touch. This, in the course of a
week, developed into a spot of superficial
gangrene.
On admission patient was a thin but well
nourished male. General examination, aside
from an incisional hernia and spot of gan-
grene 2 cm. in diameter on sole of right foot,
was negative. Both feet were cold and pur-
plish-blue when patient was erect.
During his stay in the hospital his tem-
perature ranged from 97' to 98.3° F. ; pulse
60 to 100 and respirations 16 to 22. Blood
count was normal ; no increase in leukocytes.
Repeated urinalyses at first showed less than
0.5 mgm. sugar, trace of albumin and few
hyalin casts, and later all specimens were free
of albumin, sugar and casts.
On admission his blood sugar was 168 mgm.
per 100 c.c. of blood, and on a diet of 60
gm. carbohydrates, 100 gm. protein and 130
gm. fat, his blood sugar varied between 117.5
mgm. and 90 mgm. per 100 c.c. of blood.
Blood urea was 35 mgm. per 100 c.c. of blood.
Radiogram showed heart and aorta on the whole
slightly enlarged. The aorta showed no calci-
fication. Transverse diameter of chest 26 cm.;
heart 13.5 cm.; and aorta 2.75 cm.
The patient was treated by rest in bed with
a cradle over foot holding a blue incandescent
lamp to keep feet warm and dry. He was
given daily diathermy. Attention to bowels
and general hygiene was observed. At first
the gangrenous spot tended to spread and there
was a light serosanguineous oozing. After 2
weeks the spot became entirely dry and very
slowly separated and scaled off.
As determined by the oscillometer, the cir-
culation in both legs was very poor ; less ex-
cursion of the indicator on the left than right.
Only above the middle-third of the thighs
wrere the pulsations nearly normal. Had the
trauma and resulting gangrene occurred to
the left instead of the right foot, the patient
would, in all probability, have lost the limb.
REVIEW OF RECENT LITERATURE ON
THROMBO- ANGIITIS OBLITERANS
WITH REPORT OF AN AD-
VANCED CASE*
Max Gross, M.D.
Long Branch, N. J.
This is a review of the recent literature to
call your attention to this important topic so
that an early diagnosis can be made possible,
thereby giving us a means of instituting non-
operative measures and avoiding the disas-
trous results which follow when recognized
too late; as will be illustrated by the case to
be presented.
This is a disease which has been taken out
of the confused material of arterial diseases
by Buerger. It is a characteristic inflamma-
tory lesion of the deeper arteries and veins of
the extremities, with extensive thrombosis fol-
lowed by organization and canalization, thus
matting the arteries, veins and nerves into
dense connective tissue cords. The arteries
and veins of the lower extremities are the
most frequently affected and their nerves are
included in this inflammatory process, with
accompanying migratory phlebitis in about
25% of the cases.
Etiology: Confusion still exists as to actual
cause of the disease. Various theories have
been advanced, without definite conclusion.
(1) Race. The Hebrew seems to be the
most affected, especially among Russians,
Galacians and Roumanians. It used to be a
disease considered typical of the Jewish race
but from recent reports many Gentiles have
been found to be afflicted. Cases have also
been reported in the Orient. Buerger reports,
in his book, that out of a series of 500 cases,
10 were Gentiles. However, from more re-
cent reports by Allen, Brown, and others, the
* (Read before the Monthly Conference of the
Monmouth Memorial Hospital November 12, 1930.)
572
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 19 31
total number of Gentiles recorded is around
100.
(2) Sex. This disease has a peculiar affin-
ity for the males. Females are rarely affected.
Of the same 500 patients seen by Buerger,
only 3 were females. If, as it seems to Silbert,
who will be mentioned later, tobacco is a
causative factor, the recent fad of women
smoking should add to the number of that
sex afflicted.
(3) Age. The ages range from 20 to 40
years.
(4) Infection. Buerger thoroughly believes
that the underlying arteritis is caused by an
infectious agent which may be a specific or-
ganism, although he is unable yet to prove
this bacteriologically. In a recent paper he
further tries to prove that the disease is
caused by an infectious agent ; a series of ex-
periments carried out on normal and affected
individuals and on experimental animals. He
made a coagulum of an infected vessel and in-
jected it into and around veins which were
ligated proximally and distally, and in a period
of 10 days removed the veins and made mi-
croscopic slides of them. The pathologic
picture of the removed veins which had the
perivascular coat injected was almost iden-
tical with the migratory phlebitis which is so
frequently present in this disease.
(5) Tobacco poisoning. Silbert is convinced
that the etiologic background for this disease
is intoxication from tobacco smoking, and that
everyone who gives up smoking shows a
marked improvement. He claims further that
there is an hereditary factor that makes these
victims susceptible to some intoxicant from
the tobacco. This factor he believes is in-
fluenced by the endocrine system. Many au-
thorities agree and others disagree with Sil-
bert as to tobacco being of sucb great import-
ance in this disease, but one cannot cast aside
the impression derived from case reports of
the patients becoming improved as a result
of refraining from smoking.
(6) Other theories have been advanced,
none of which has any background and will
not be discussed here. The diet of the He-
brew has been considered of importance in
the etiology.
Symptomatology: Most of the symptoms
are due to the thrombotic healing rather than
the inflammatory lesions.
(1) We have phlebitis migrans accom-
panying the superficial veins in 25% of cases
which may affect the lower or upper extremi-
ties; the deep veins are affected in 40% of
the cases. An attack of such a nature with-
out obvious cause should make one suspicious
and lead to a thorough investigation of the
blood vessels. However, if such a condition
exists in the arms, careful search should be
made of the lower extremities as regards the
deep vessels.
(2) Pain. This consists, first, of pain of
an acute inflammatory nature, which is a
vague ache, deep seated and independent of
accompanying paroxysms and tenderness in
the calves ; second, pain of the intermittent
claudication type which is manifested by
cramp-like or lancinating pain in the muscles
of the calves or a diffuse ache throughout the
leg coming on with exertion and ceasing with
rest ; third, pain accompanying or preceding
trophic lesions, which is most frightful. A
small fissure, bleb, or ulcer may be the site of
the most agonizing type of pain and usually
is the precursor of gangrene.
(3) Ischemia is a pallor or blanching ob-
tained by raising the limb. Persistence of
pallor when the extremity is in the horizontal
or dependent position is suggestive of an early
gangrene in that region.
(4) Erythromelia is a hyperemia and is
almost always present. It is a purplish dis-
coloration of varying intensity, which begins
in the toe and gradually extends upward.
There are 2 types: first, the induced type,
brought on only by elevation of the limb ;
second, the chronic type, which is present
while the extremity is kept in any position be-
tween horizontal and the dependent, at room
temperature.
(5) Obliteration of the pulse. This is com-
monly seen in the dorsalis pedis artery, next
the posterior tibial, the popliteal, more rarely
the femoral, radial or ulnar, and occasionally
the digital or interossei. Superficial oblitera-
tion of the vessel is easily felt but one must
bear in mind that the deep vessels which are
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
573
obliterated are not so easily accessible to pal-
pation. One must remember also that Buer-
ger’s disease can be present even though the
arteries have not been obliterated. In 5% of
the cases seen at the Mayo Clinic the pulsa-
tions of the dorsalis pedis and tibial arteries
were seen and occlusion involved mostly the
interossei and digital arteries. Constam. of
the Mayo Clinic, reports that in 24 out of 94
cases involvement of the vessels was seen in
the upper extremities. In most of the cases,
however, the lower extremities are afifected
and then the upper. Allen has reported cases
in which he found the radial and ulnar arteries
only slightly diminished in their beats but
found the interossei and digital vessels of the
hand definitely afifected.
(6) Trophic changes as seen only late in
the disease ; due to the fact that the disease
affects young people who are able to develop
good collateral circulation. However, due to
slight trauma, fissure, pustule or bleb, we may
have an increase in pain and the development
of gangrene.
(7) Interesting is the fact that people suf-
f erring with thrombo-angiitis obliterans show
some coronary changes, some of them being
of the same pathologic process that goes on in
the extremities. The most important vessel
involved is the left coronary. It is, rather
surprising that very few autopsies have been
performed in Buerger's disease. This is prob-
ably due to the fact that a pathologic diag-
nosis was made from the amputated leg, and
the rather generally accepted idea that only
vessels of the extremities were affected. In
his book, Buerger reports 4 autopsies, 3 of
which showed coronary changes, the patho-
logic picture being similar to that of the ex-
tremities. The cases reported by Perla and
1 by Lemann with autopsy findings showed
similar coronary changes.
It would be an interesting point to obtain
electrocardiograms of every person afflicted
with thrombo-angiitis obliterans to note the
relation of coronary changes in this disease.
Having this in mind, many more cases of cor-
onary disease would show changes similar or
identical pathologically to the vessels in the
extremities.
(8) The usual laboratory examinations in
this disease show nothing characteristic. Re-
moval of a vein showing migratory phlebitis
may make possible an early diagnosis. Many
authorities claim that there is an increase in
the number of red blood cells, platelets and
hemoglobin in this disease. Still others be-
lieve that there is a hyperglycemia.
Differential diagnosis. About 90% of the
cases can be divided according to Brown’s
classification into vasomotor and organic
groups, by the presence or absence of the pul-
sations of the arteries that are usually palp-
able. However, 30% of the cases of throm-
bo-angiitis obliterans show vasomotor dis-
turbances, and one must remember that gan-
grene may develop in this disease even when
pulsations of the vessels are felt, because in
these vessels the obliteration takes place dis-
tally to the area of palpation. In other cases
there is much difficulty encountered, and con-
fusion exists as to differentiation of vaso-
motor thrombosis and organic changes in the
vessels. This may be particularly true in
cases where upper extremities are involved.
A satisfactory classification has not yet been
given for diseases of the blood vessels. Buer-
ger has attempted to divide them into 2 types :
first, those of vasomotor disturbances which
include Raynaud’s disease, erythromelalgia ;
and second, organic, such as arteriosclerotic
changes in the vessels, thrombo-angiitis ob-
literans, etc. Peri-arteritis nodosa must also
be included in the second group. Early in
the disease the occurrence of indefinite pains
leads one to the diagnosis of rheumatism,
neuritis, gout or flat feet. The following are
the most important diseases which may be
confused in the beginning with thrombo-
angiitis obliterans :
( 1 ) Erythromelalgia. Arterial circulation
here is bounding and stronger during the at-
tack, redness is paroxysmal — disappears on
deep pressure and returns quickly. No ische-
mia is present and pain is brought on by pres-
sure but there is no intermittent claudication.
Trophic lesions are very rare, gangrene is of
the Raynaud’s type, and the vessels pulsate.
Females as well as males, and all races are
equally affected, and this is a symmetric lesion.
574 '
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
(2) Raynaud’s disease. About 70% of these
cases are in women; the upper extremities
being mostly involved. The lesion is sym-
metric, with attacks of local syncope, asphyxia
and rubor. The veins are not pulseless, and
redness does not disappear on raising the limb.
Intermittent claudication and phlebitis are ab-
sent. The x-rays show atrophy of the terminal
phalanges.
(3) Arteriosclerosis. This occurs usually
in older people, blanching and rubor are not
so regularly present, arteriosclerotic gangrene
is of the moist type, and its occurrence in the
upper extremities is rare. X-rays may show
calcified arteries and they are distinctive here.
However, one must remember that arterio-
sclerosis may be superimposed upon a Buer-
ger's disease.
Treatment. The impression that the dis-
ease finally ends in amputation is combated
by Silbert, who holds the optimistic view that
the disease can lie checked by proper and
newer therapeutic measures, whereas the
earlier treatment resulted usually in that 85%
of the cases came to amputation. Spontaneous
improvement has occurred but as the patient
is further watched he is bound to have a re-
lapse which within a few months may lead to
gangrene.
Silbert has studied 258 cases that were un-
treated and found that 77% of 155 cases re-
quired, within 5 years, amputation of one ex-
tremity. In another series of 200 cases treat-
ed under a single method he claims that in a
period of 1-5J4 years only 10% of the cases
came to amputation, and of these some were
far advanced when they first appeared for
treatment. He goes on to say confidently that
if cases are recognized early, amputation will
become a rarity. Prognosis under treatment
depends greatly upon the circulatory de-
ficiency, and palpation cannot determine that,
so he resorts to the Paclion oscillometer and
can thus early detect cases. With this method
we have 2 distinct major groups: first, those
having an oscillometric reading of or more
at the ankle of the affected extremity, with
an excellent prognosis ; second, those having
a reading of zero or less than */-> in advanced
cases, and if gangrene is present amputation is
inevitable. Of course, prognosis depends
upon the collateral circulation being sufficient
to maintain nutrition.
Various methods have been advanced as to
treatment, the most important of which will
be taken up :
( 1 ) The use of hypertonic salt solution,
which consists of a 5% salt solution in dis-
tilled water. The modus operandi is claimed
by Silbert to be a mechanical one in that it
increases the blood volume, by repeated in-
jections, of the collateral circulation; this re-
sults in a dilatation of the existing vascular
channels and the opening up of new capillary
channels. No specific effect of the salt is
expected and salt is used because it is least
toxic. His first dose is 150 c.c. and subse-
quent doses 300 c.c. At least 7-10 minutes
are allowed for each injection, and they are
given 3 times a week and reduced as improve-
ment takes place. The only effects at the
time of injection are a sense of warmth and
thirst, accompanied by flushing of the face or
engorgement of the veins. It takes at least 48
hours to excrete 15 gm. of salt and that is
why only 3 injections are given a week. A
febrile reaction indicates a foreign protein in
the salt ; usually the resultant of bacterial
growth. Repeated injections have caused a
certain, amount of destruction of red cells,
but the patients have an increase in the blood
elements and Silbert thinks it is of no conse-
quence. Cardiac or renal impairment in a
patient over 60 years of age is a contrain-
dication to its use. Silbert has given some-
where around 13,000 injections without any
fatality. He claims that improvement may
be seen within a few weeks and the first sign
is an increase in the warmth of the affected
part of the extremity with subsequent de-
crease of pain. Most gratifying, are results
obtained in early cases. We thus have an
increase in temperature, growth of nails, later
healing of the ulcer. In addition to these in-
jections, rest in bed, hot foot baths, baking,
diathermy and exercises recommended by
Buerger are given.
(2) Typhoid vaccine. Injections are given
as advocated by Allen and Smith. This raises
the temperature from 1 to 2° and is believed
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
575
by some to be just as beneficial as some of
the surgical procedures recommended.
(3) Insulin injections have been advocated.
No final statement can be made as to its value,
as not enough cases have been reported to
show its benefit, and the theory is very defin-
ite. Perhaps the question of a hyperglycemia
may have some foundation. Insulin injections
of from 10-15 units are given 2 to 3 times a
day and may be of value in helping pain.
However, it should be preceded by a glass of
orange juice to combat any hypoglycemic re-
actions that may arise.
(4) Peri-arterial sympathectomy, as ad-
vocated by Leriche and others, has been tried
with some success. Considering the anatomy
of the sympathetic system, and especially that
supplying the blood vessels, it will be plainly
seen that this form of operation is a waste of
time. The operation as advocated by Hunter
and Royle is that ramisection has been of
value but not enough cases have been report-
ed to have any final say about it. Ganglionec-
tomy has also been performed, some claiming
success, others refuting it. A similar method
has been tried by exposure of ganglion to
Roentgen rays with temporary relief only.
However, all these operations are temporary
in effect and just as good results can be ob-
tained by nonoperative means.
(5) Surgical treatment. Of course, con-
servatism is uppermost in these cases and
operations should be deferred as long as pos-
sible to allow nature to form a collateral cir-
culation. Silbert believes that nature should
be given a chance to allow circulation to form
and often nature performs a spontaneous
amputation of the gangrenous toe. A major
operation should be done only in the face of
rapidly spreading gangrene even though in
the presence of infection and ascending
lymphangitis. Silbert treats his cases with
simple drainage and wet dressings, with some
good results. Trauma and infection must be
guarded against. Unfortunately, some pa-
tients come too late, but even here he believes
that a trial of salt solution should be made.
Silbert advocates ' amputation below the knee
because an artificial leg functions much bet-
ter with a natural knee-joint; however, ac-
cording to Harvey and Oughterson, if there
is evidence of a possible arteriosclerosis
superimposed on this disease it is better to
amputate above the knee.
Case History. M. R.. white, male, Hebrew,
American, 31 years of age, married, with no
occupation for the past 5 years, entered the
hospital October 17, 1930, complaining of
severe backache and severe pain in the right
wrist.
For the past 3 weeks, he had experienced
sharp, stabbing pains in the lower back, which
radiated to the front and into the groin on
the left side, lasting 6 or 7 hours and nof
easily relieved by opiates. No nausea or vomit-
ing accompanied the pains. The latter are
intermittent, occur almost every day, are of
the same nature and almost always double
him up. At the time of these attacks he has
had difficulty in starting his stream when
voiding but with no polyuria, frequency or
hematuria. He claims to have passed a stone
from the bladder 7 years ago and one 4 years
ago when he had similar attacks but they were
not as severe as now. For the past 7 years
he has had a dull aching pain in his back,
which was constantly present but was not
severe enough to alarm him. Also complains
of sharp, stabbing, cramp-like pain across his
right wrist- joint shooting along the ulnar side
so that at times he does not feel the presence
of his fingers at all. These attacks occur al-
most every other day, at times twice a day,
and he is rarely free from them for more
than a week. They come on with such sever-
ity that they drive him to the “verge of sui-
cide”. At times he has “pins and needles”
sensation in the tips of his fingers and during
such attacks the right hand becomes very
pale, taking a long time to return to its normal
color, and being colder than its fellow. This
has occurred intermittently for the past 8
months.
About 12 vears ago, while a member of the
27th Aerial Pursuit Group, A.E.F., in France,
both feet became numb and cold. Later he
had “pins and needles” sensation, and the
army medical man told him he had frost-
bitten feet and a touch of rheumatism. From
that time on he suffered with pain in both
5 76
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
legs but more so with the right, and the least
exposure to cold caused him great suffering.
He had these attacks for 8 years, being seen
by various medical men who diagnosed it
“rheumatism”, “flat feet”, “neuritis”, etc.,
without any help to his condition. Four years
ago the pain became unbearable in his right leg
and he was unable to stand on that foot. He
was recommended to Dr. Buerger with a diag-
nosis of “thrombo-angiitis obliterans”. He was
hospitalized, given intravenous saline, Buer-
ger’s exercises, etc., without satisfactory bet-
terment. An amputation just above the knee
was performed by Dr. Buerger.
Five weeks later the patient fell and hurt
his stump, resulting in a tumor formation
which later discharged a seropurulent material
and showed no signs of healing. He was
sent to the Brooklyn Naval Hospital where a
second amputation was performed 3 in. above
the first and good healing resulted.
The patient went around on crutches for a
period of 3 years. In the meantime, his left
leg began to bother him and he experienced
the same symptoms as in the right leg. He
was unable to walk a block without getting
cramp-like pains in his left leg. One year
later he went to the Brooklyn Naval Hospital
where he received intravenous typhoid vaccine.
He developed a severe reaction from the treat-
ment, necessitating the use of adrenalin. At
the same time he experienced a tingling sen-
sation of the right hand. The toes on his
left foot felt like “ice” and at other times
“hot”. He developed an abrasion on the left
big toe, and one on the second toe which in-
creased the pain. He was sent to the Marine
Hospital at Key West, Fla., where he had a
partial amputation of the anterior-third of
the left foot. He again experienced very
sharp pain in his leg so that an amputation of
his left leg between the hip and thigh was
performed at the St. Francis Hospital, De-
cember 14, 1929, where he made a good re-
covery.
Past history: Had measles and whooping
cough.
Habits : Nothing unusual except that he
smoked about 40 cigarettes per dav and since
the onset of new pains he smokes even more.
There is nothing unusual in the family his-
tory. His occupation was that of a painter
since boyhood. However, since loss of both
extremities he does not do anything.
Previous hospitalization : Entered Mon-
mouth Memorial Hospital February 27, 1927,
complaining of pain in the right leg. A diag-
nosis of “plumbism” was made and also Buer-
ger’s disease was suspected. Entered again
August 15, 1927, complaining of intermittent
sharp pains in both feet. Diagnosis was
“acnte foot strain”. He was in again on
November 22, 1927, complaining of the same
pain. Definite rubor changes were seen in
the right leg and foot as compared to the left.
Diagnosis— -Buerger’s disease. On July 9,
1930, he entered the hospital with both 'legs
amputated and complaining of sharp stabbing
pain in the left groin with a lump in scrotum.
Diagnosis — • thrombosis of left spermatic
veins, probably of same nature as that of the
legs. He returned 3 days later with acute
pain as on July 9, which has radiated to the
left lower quadrant, with spasm and tender-
ness of the left rectus muscle. In the last 3
admissions he complained of severe pain in
the right hand and wrist.
Progress : The patient was in the hospital
fully 3 weeks. The pain in the left kidney
area disappeared within a week. However,
the intermittent claudication of the right
hand became progressively worse. The at-
tacks were agonizing, driving him to threats
of suicide. Almost a grain of morphia would
not hold him. Everything in the line of pal-
liative means failed to help. Insulin was
tried without avail. Persuaded to refrain from
smoking.
When the patient was discharged, one of
our physicians called 3 or 4 times a week, and
patient was no better; is now in Florida,
thinking that the climate would be of benefit
to him.
Summary: We are dealing here with a
disease which is almost in the last stages of
thrombo-angiitis obliterans. Here is a pa-
tient who had the disease almost 9 years be-
fore it was recognized and when it was diag-
nosed it was too late for nonoperative treat-
July, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
577
ment. This proves the great difficulty of
recognizing the condition in its early stages
unless we bear in mind possibility of the dis-
ease in people who complain of pain in the
legs or hands. It also teaches us not to make
a diagnosis of “flat feet" or “foot strain” un-
less we have ruled out Buerger's disease.
When presenting the patient at the confer-
ence, he complained of severe pain in the left
cubital fossa. On examination he showed a
definite migratory phlebitis of the median
cubital vein extending for about 4 in. with
palpable nodosities along the newly inflamed
vein. At the same time he had intermittent
claudication of the left hand.
It would be interesting if one could de-
termine the cause of his pain in the left lower
back, which was so typical in the history of
renal colic or stone. Are we dealing here
with some thrombotic process in the left renal
vein? Was it a migratory phlebitis of that
vein? Radiographs of the kidneys were nega-
tive. In view of these negative findings one
would be inclined to think that this is a part
of the general disease which has attacked so
many other vessels.
Another interesting thing is his intermit-
tent pain in the precordium. Here again one
would be led to the idea that the coronary
vessels are a part of the same thrombotic pic-
ture seen elsewhere, in view of the extensive
involvement in the other parts of the body.
Neither an electrocardiogram nor physical
findings of coronary involvement are positive.
Only microscopically can it be proved to be
thrombo-angiitis obliterans. Nevertheless, cor-
onary involvement is to be thought of in peo-
ple suffering with Buerger’s disease.
THE BELL BUOY
Ralph S. Cone, M.D.
Rising and falling
With the swell.
The bell buoy tolls
A funeral knell,
Ringing ceaselessly,
O’er the shoal ;
Peace to the unknown
Sailor’s soul !
Rumbling upon
Thy lonely shores
Like the wind
In the chimney roars ;
Sad one, watching
By the sea,
What could the cruel
Waves tell to thee !
But merrily,
Mockingly, they rave
And the bell buoy tolls
O’er the wanderer’s grave
Doth absence make
Thy love grow fonder?
Wild heart, be still.
He waits thee yonder !
578
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
Economics
FAMILY DOCTOR’S INCOME IN RELA-
TION TO PREVENTIVE MEDICINE
(Editorial from the Wisconsin Medical Journal,
March 1930, part of which was taken from
the American Journal of Public
Health, January 1930.)
From time to time the question is raised as
to what effect the extensive program of pre-
ventive medicine that is developing in many
parts of the country will have on the income
of the practicing physicians. The falling
death and morbidity rates in all parts of the
country compel recognition of the fact that
this question has other than academic signifi-
cance. Thinking persons realize that the prac-
tice of medicine is no more a static condition
than any other human relationship. In the
evolution of social adjustments, the means
and mechanism of furnishing necessary hu-
man service must be modified to meet chang-
ing conditions. The shrewd horse trader long
ago sold his livery stable and bought a gar-
age. The physicians of the kerosene era ob-
tained a large part of their income from the
treatment of diphtheria and infantile diarrhea.
While preventive medicine has reduced the
physician’s income from both these sources
almost to the vanishing point, the physician of
the gasoline age has more practice of a far
better kind.
Mathematic demonstration of this state-
ment may be presented with available figures.
The last year for which figures on diphtheria
rates of the various states of this country are
obtainable is 1927. In that year there were
82 cases of diphtheria reported in the state
of Michigan for each 100,000 population. A
comparison of incomes to the physicians be-
tween fees received for treatment of cases
and those paid for immunization of babies re-
veals that even where the disease has the
above unusual prevalence, preventive medi-
cine is as productive financially as curative
medicine. The income from treating 82 cases
at $50 each would be $4100. Among each
100,000 population in the state of Michigan in
1927, there were 2200 babies born. If each
of these babies had been immunized at only
$3 each, the income from this practice in 100,-
000 population would have been $6600. It is
also to be noted that these data predicate only
the immunization of the new-born, or an
equivalent number of persons in the commun-
ity. There are of course 4 times as many
preschool children as babies, and 10 times as
many school children. The opportunity for
increasing practice by carrying on immuniza-
tion among the preschool and school popula-
tion in the physician’s clientele offers an al-
most unlimited field.
I had occasion to visit the dentist the other
day. Because I had postponed the visit too
long, some of the necessary repair hurt a
good bit more than as though it had been done
earlier ; and, the bill was larger. When I was
dismissed, the doctor asked: “Would you like
to be placed on the 4 months’ list?”
He then explained that people forget about
inspections and the dentist until the night
that toothache awakens them, and said that
the “4 months’ list” meant that at the end of
each fourth month his assistant would call for
an appointment, — and call repeatedly until I
did come in. I, like 75 other patients of that
particular dentist, was pleased with the sug-
gestion.
If that pleases the patient of the family
dentist, why should it not please the patient
of the family physician? I venture to sug-
gest that it would.
ARE WE UNDERPAID?
(An article by Dr. H. M. Tolleson in Medical
Economics, February 1931.)
There is much ado about the doctor’s fee,
methods of collecting, and like problems. Here
is a thought not so much discussed in the
meetings of our medical societies and in the
editorial columns of our journals :
There is one way in which a doctor, a real
physician, is paid that isn’t entere'd on his
ledger. There is one form of compensation
that doesn’t come under the income tax re-
port.
Have you; Brother Physician, ever experi-
enced the feeling of satisfaction and gratifica-
tion that comes like warm sunshine permeat-
ing the drab, sordid grind of the day’s wyork
from the sight of a helpless infant gradually
growing stronger under your care?
Has you heart been touched and your eyes
moistened as a mother looks up at you with a
glowing face as she holds a baby who is re-
covering from the brutal attack of disease,
recovering as a result of your timely inter-
vention ?
Do you recall that night when you sat be-
side the patient as he passed his crisis and
the anxious little wife and bewildered little
children looked up to you and put all their
trust and faith in you ? And then, when you
could safely say, “He is out of danger, Mrs.
Brown” — do you recall that look, that “Thank
God — and the Doctor!”? Did you collect a
fee 1 Whether you did or not. Doctor, were
you underpaid?
July, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
579
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J.
Entered at the post office at Orange, N. J., as seccnd-class matter
PUBLICATION COMMITTEE
HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J.
EDITOR:
HENRY O. REIK, M.D., F.A.C.S., Vermont Apartments, Atlantic City, N. J.
Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing ta
receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fact.
NOTE. — The transaction of business will be expedited, and prompt attention secured if:
All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to
The Editor, Dr. Henry O. Reik, Vermont Apartments, Atlantic City, N. J.
All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements,
or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication
Committee, (address above), Newark, N. J.
ASBURY PARK CONVENTION
The 165th Annual Meeting of our vener-
able State Society, held at Asbury Park, June
2-5, was no less interesting than the many
similar previously held conventions of this
organization. Good weather conditions pre-
vailed throughout the week, and proximity to
the larger centers of population embraced in
the counties of Essex, Hudson, Mercer, Mid-
dlesex, Morris, Passaic, and Union, favored
an increase of attendance. The total regis-
tration did not, however, reach the high fig-
ures established in Atlantic City — only 890 in
all as compared to 1065, and 310 members
exclusive of delegates and officers as against
459 — lint the percentage of elected delegates
present 180%) was unusually large. Only 2
Fellows and 3 Trustees were absent. There
were, however, 2 attendance drawbacks to the
success of the meeting : many of the regis-
trants from the northern portion 'of the state
drove by automobile from and back to their
homes the same day, merely “looking in”
upon the convention ; and, several of the
southern counties were very poorly repre-
sented (3 without representation at the meet-
ing of the Nominating Committee) because
of the inaccessibility of Asbury Park by rail-
road.
The figures at hand do not enable us to cal-
culate the effect upon attendance resulting
from abolition of the Permanent Delegates,
but we are inclined to think it was less than
had been feared. Two years ago, we editor-
ially expressed the belief that “the old de-
pendables” would continue their interest in
the organization, and a superficial view of the
recent meeting tended to confirm that opinion.
A sense of gloom hovered over the Trus-
tees’ meeting Tuesday night and the opening
session of the House of Delegates on Wed-
nesday, because of the death of Dr. Hunter,
a former President and until Tuesday morn-
ing, Secretary of the Board of Trustees. Dr.
Hunter had packed his bag, including his of-
ficial papers completed up to the minute, and
retired to bed with the intention of making an
early morning start to drive from Westville
to Asbury, and ere normal sleep could come
he was stricken by coronary thrombosis and
lived but a few minutes thereafter. In his
passing, the Society lost one of its safest,
sanest and most efficient organization work-
ers, as well as one of its most illustrious mem-
bers.
At this meeting, President Sommer closed
a year of marked activity in the presidential
office, and presided over one of the busiest
sessions the House of Delegates has ever held.
The amount of work inaugurated during the
past year, considered by the Delegates, and
advanced to his successor, is indicated by the
large number of special committees provided
for to carry on the projects approved and
resolutions adopted.
The scientific program for the general ses-
sions was not up to standard and its presen-
tation suffered further from the lack of an
audience Friday afternoon. The exodus of
those who had been chiefly interested in the
business and political conferences of Wednes-
day and Thursday, and the fact that so many
580
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
members merely dropped in for part of one
day, and made choice of that day which af-
forded the greatest amount of entertainment,
serve to explain the fiasco of the last after-
noon session.
All of the sections were well attended, and
a movement was launched to establish next
year a Radiologic Section.
The Woman’s Auxiliary apparently had a
very satisfactory meeting and is progressing
as well as could be expected.
We hope to publish the “Official Transac-
tions” this year along with the August Jour-
nal.
ENTERING UPON A NEW FISCAL
YEAR
At the close of the Asbury Park meeting,
Dr. John F. Hagerty, of Newark, ascended
to the presidency of the state society and
opened a new year of the organization’s work.
No more worthy person could have been
selected from the society’s membership for
this honor. In the city of Newark, where he
is best known. Dr. Hagerty is universally
loved and respected, as a surgeon of great
ability, a physician of professional distinction,
and a man of the highest probity. He is tak-
ing leadership in the society at a critical
moment in its life, a time when questions of
the most serious import are demanding con-
sideration and, if possible, solution, but all
who know him feel that he will prove himself
an active, wise and courageous leader. As
will be seen later, in reading the convention
transactions, he is instructed or authorized to
appoint an unusually large number of com-
mittees to study a variety of problems. Every
member, as appointed o: called upon for ser-
vice, should give him all possible assistance in
his efforts to conduct the affairs of this so-
ciety satisfactorily.
The election of other officers resulted in
promoting Dr. Lancelot Ely, of Somerville,
from Chairmanship of the Committee on
Scientific Work to the position of Third Vice-
President. Dr. Ely has represented his county
faithfully and well in the work of the Welfare
Committee for a number of years, besides
having filled all the offices of the Somerset
County Society.
STATE SOCIETY TRANSACTIONS
It has been customary to publish the com-
plete transactions of the Annual Meeting as
a Supplement to either the August or Septem-
ber Journal, depending upon receipt of the
reporter’s transcript. This year olir meeting
was held a week earlier than usual, and the
reports are being received with sufficient
promptness to justify the expectation that the
proceedings can be published early in August.
In consequence of that hope, it seems unneces-
sary to present this month any elaborate sum-
mary of the happenings at Asbury Park, but
our readers who were deprived of the privi-
lege of attending the convention will doubt-
less want to have some news of the event.
At the opening session of the House of
Delegates, on Wednesday morning, President
Sommer called attention to an unfortunate
feature of the Constitution and By-Laws,
which provides for delivery of the Presiden-
tial Address at a fixed time that is not reached
until after the Delegates have completed their
work upon the Society’s business affairs. As
lie pointed out, at the conclusion of his term
the President should have some recommenda-
tions to offer and advice to give as the result
of experience. Dr. Sommer met that situation
by at once presenting an abstract of his pre-
pared address, but some provision should be
made by law makers of the society to correct
the complication.
Perhaps the most marked feature of the
convention was the amount of new business
introduced and the number of problems of-
fered for solution. The incoming President
was authorized to appoint special committees to
investigate and study such questions as state
medicine, classification and control of special-
ism. the Workman’s Compensation Law,
amendment of the Hospital Lien Law, pro-
vision in the Medical Practice Act for a griev-
ance committee, urging the Motor Vehicle
Commissioner to require more complete
physical examinations of those seeking license
to drive automobiles, revision of the state
health laws, cooperation with the Board of
Education regarding health measures applic-
able to school and pre-school children, and
others that escape our thought at the moment.
July, 19 31
JOURNAL OF THE MEDICAL
SOCIETY OF NEW JERSEY
581
Medical Ethics
MEDICAL SOCIETIES
John Hammond Bradshaw, M.D., F.A.C.S.,
Orange, N. J.
“In order that the dignity and honor of
the medical profession may be upheld, its
standards exalted, its sphere of usefulness
extended, and the advancement of medical
science promoted, a physician should as-
sociate himself with medical societies and
contribute his time, energy and means in
order that these societies may represent
the ideals of the profession.’’ — Principles
of Medical Ethics, A.M.A.
We find it the case inside and outside the
profession that some men like clubs and some
detest them : And while a medical society in
many ways is a club, it is also in many ways
very different. Generally speaking, a “club-
able” man is glad to join a medical society.
But there is no special obligation for a man to
be an Alpha Delta Phi or an Elk, a Rotarian,
or even to join his Country Club in the sense
that he should join his local medical society,
his county medical society (and the American
Medical Association), and, if he is a special-
ist, some regular organization that represents
his special work.
In social clubs, the advantages are mostly
social, whereas the medical society is, rightly
speaking, almost altruistic as well as social,
highly educational, and its chief object is the
advancement of medical science. No doctor
in his own interest can neglect his medical so-
ciety. If he does so, his own is the chief and
only loss.
Look at the names of the great leaders of
the medical profession and you will be amazed
to find so few of them who are not also lead-
ers in medical societies. These societies are
the clearing houses in their different localities
for medical thought. They stand in the medi-
cal world as the Stock Exchange does in fi-
nance, for here you get increase in your stock
of medical knowledge, and in our medical ex-
changes the losses are few and the profits are
great.
Dr. Osier wrote of this subject, membership
in the medical society, with his unusual un-
derstanding :
“But, after all, the killing vice of the
young doctor is intellectual laziness. He
may have worked hard at college but the
years of probation have been his ruin.
Without specific subjects upon which to
work, he gets the newspaper or the novel
habit and fritters his energies upon use-
less literature. There is no greater test
of a man’s strength than to make him
mark time in the ‘stand and wait’ years.
Habits of systematic reading are rare,
and are becoming more rare, and 5 or 10
years hence, as his practice begins to
grow, may find the young doctor know-
ing less than he did when he started and
without fixed educational purpose in life.
Now here is where the medical society
may step in and prove his salvation.”
(Italics mine.)
But even medical societies can have their
diseases ; which may even cause gangrene and
death. A certain amount of well directed pol-
itics is absolutely essential to the preservation
and advancement of any society. But if this
is misdirected and actuated by selfish motives,
medical politics can cause dry rot.
Esthetics
CULTURE
(This article, taken from the front cover page of
the American Medical Association Bulletin of
May 1931, was abstracted from The Dip-
lomats by Thomas G. Orr, M.D.)
“Any professional man is hardly doing his
full duty to himself and to the profession he
represents unless he gives some time to edu-
cation and cultural improvement. I am con-
vinced that by so doing in medicine one will
make a better physician. Even a doctor is
partly judged by his general information of
affairs, and, therefore, cannot afford to neg-
lect all the better things in general education.
Eben Holden was right when he said : ‘Got t’
judge the owner as well as the hoss. If there’s
anything the matter with his conscience it’ll
come out in the hoss somewhere.’ A doctor
cannot afford to be substandard in things edu-
cational or the evidence will crop out some-
where and his shortcomings be made evident.
Education keeps us out of a rut, it demands
respect, and, of equal importance, it is a last-
ing pleasure. Education and culture go hand
582
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
in hand. Culture is quite difficult to define,
and I am confident that many times it exists
in outward show and mannerisms only. A
mother may teach her son to tip his hat to
women and to stand in the presence of her
guests, but he will not be cultured if he lies
to her about his escapades or steals from his
neighbors. Most men of science are led to be-
lieve that many of the qualities that go to
make up an educated and cultured gentleman
are inborn and cannot be the result of envi-
ronment only. Such a heritage does not mean
family or social position. ‘The creature we
call a gentleman lies deep in the hearts of
thousands that are born without chance to
master the outward graces of the type.’
(Owen Wister.) If the qualities that lead to
education and culture are born in a man, he is
fit to become a doctor.”
Concerning the last mentioned aspect of the
question, the degree of culture desirable in a
prospective physician, the Journal of the
Michigan State Medical Society, of Tune
1931. contained an interesting editorial from
which we quote as follows :
“Culture is an elusive entity; it is of a class
of words such as light, life, death, difficult to
define, yet its manifestations are clear to ev-
eryone. Nor in our opinion can culture be
acquired by memorizing Elbert Hubbard's
scrap book nor by 15 minutes a day with El-
iot’s 5 ft. book-shelf, as interesting as these
may be. We can see how such a course might
make of a man or woman an intolerable bore.
Externally we associate culture with neat-
ness of attire, with carefulness combined with
ease in speaking, with a voice that is not un-
pleasant. We can hardly conceive of a cul-
tured man who is not educated, but there are
many educated persons who are anything but
cultured. The cultured life may be built upon
a book foundation. The cultured person is
critical in his outlook on life. In other words,
he does his own thinking and accepts truth
only on evidence ; yet. he is tolerant where
tolerance can be considered a virtue, which it
is not always. He should aim at accuracy,
avoid cock-sureness of statement, and never
hesitate to acknowledge his limitations. Yet
all this is not a definition. We are inclined
to place the term culture in the same category
as personality, a word we were never able to
define to our satisfaction.”
In Lighter Vein
Home Treatment
“Good morning, Mrs. Kelly,” said the doctor,
“did you take your husband’s temperature, as I told
you?”
“Yes, doctor, I borrowed a barometer and placed
it on his chest; it said ‘very dry,’ so I bought him
a pint o’ beer an’ he’s gone back to work.” — Bos-
ton Transcript.
Those Luscious Accents
Wife — “John, is it true that money talks?”
Husband — "That’s what they say, my dear.”
Well. I wish you’d leave a little here to talk to
me during the day. I get so lonely. — Bennington
Banner.
Desperate Moment
Mother — “Johnny, if you eat more cake, you’ll
burst.”
Johnny — “Well, pass the cake and get outa the
way.” — Boston Young Men’s News.
Explained at Last
“Well, you’ve got one of them ear things for
your deafness at last. That's what I’ve been tell-
ing you to do for 5 years.”
“Oh ! That's what you've been telling me for
5 years, is it?” — Punch.
Friend of the Stork
The doctor of a country village had 2 children
who were acknowledged by the inhabitants as be-
ing the prettiest little girls in the district.
While the 2 children were out walking one day,
they happened to pass quite near 2 small boys;
one lived in the village and the other was a visitor.
“I say”, said the latter to his friend, “who are
those little girls?”
“They are the doctor's children,” replied the vil-
lage boy. ‘ He always keeps the best for himself.”
— Montreal Star.
Doctor — I suppose, Mrs. Johnson, that you have
given the medicine according to directions.
Mrs. .Johnson — Well, doctah, I done mah bes’.
You said give Sam one o' dese heah pills 3 times a
day ontil gone, but I done run out o' pills yistaday
an' he hain't gone yet.
Joshaway Crabapple says:
“Wooden legs are not inherited; wooden heads
often are.”
Consulting the Oracle
Gentleman (at police station) — “Could I see
the man who was arrested for robbing our house
last night?”
Desk Sergeant — “This is very irregular. Why
do you want to see him?”
Gentleman — “I don't mind telling you. I only
want to ask him how he got in the house with-
out awakening my wife.” — Harvard Lampoon.
There's No Perfect Crime
Betty — “How did mama find out you didn’t really
take a bath?”
Billy — “I forgot to wet the soap.” — Boston Trans-
cript.
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
583
Lighthouse Observations
COMBINATION" ANESTHESIA
Much has been written recently about anes-
thesia and anesthetics — general, spinal or intra-
venous— and a variety of drugs usable by one or
other of these methods. The reasons for such
consideration are well stated by Willard Bartlett
(Jour. Missouri Med. Assoc., 28:43, January 1931):
“No one now alive remembers the period when
it was current practice to tie or hold a patient
down during a harrowing surgical procedure.
Having this picture in mind, the surgeon of an
earlier day must have been more than satisfied
when the introduction of ether and chloroform
forever freed the sufferer from the torture that
had been his while on the table. Are we now,
nearly 100 years later, keeping step with progress
in other fields unless we make every effort to
overcome the anxiety, insomnia, restlessness,
nausea, sweating, pain and thirst which custom-
arily precede or follow surgical operations? If we
eliminate these, we can accomplish 4 desirable
ends by diminishing the likelihood of (a) respira-
tory complications, (b) vomiting, (c) distention
and (d) bladder paralysis.
Up to May 1 of this year we had studied the
effects of veronal and luminal upon 1218 patients,
having in mind widening the scope of surgical
anesthesia. This- paper gives the result of our ex-
perience with 190 individuals who, in the accom-
plishment of our anesthesia plan, took relatively
large amounts of luminal, the drug being admin-
istered in a single dose to 134 of them, and in
broken doses to the remaining 56.
Our patients are carried for about 36 hours in
what may be called a dream-state, being actually
unconscious during the operation only. They are
more or less responsive at all times, seem wholly
rational, answer questions, but manifest no in-
terest in their surroundings then and later retain
only the haziest, if any, recollection of this entire
period and its happenings. Our prolonged semi-
anesthesia renders it unnecessary in goiter cases
to operate outside the operating room, or, indeed,
to start gas in a patient’s bed no matter how toxic
she may be; she is indifferent to the change from
bed to operating table, hence no psychic damage
is done.
Every satisfactory anesthesia is a compromise
between advantages gained and risks taken. One
does not claim that a drug so potent as luminal,
for example, is utterly harmless; it cannot pos-
sibly be harmless. Still, it has seemed in our
hands to have greatly reduced the need for much
of the more dangerous anesthetic substances and
at the same time to have possessed advantages
not inherent in them. It is easy to exceed the
proper dose of any sedative drug, thus risking the
pathologic rather than the wanted physiologic ef-
fect. With this axiom in mind we endeavor to
induce a mild anesthetic state of from 24-36 hours’
duration by superimposing upon one another the
influences of luminal, nitrous oxide (sometimes
ethylene), one dose of morphin if great postoper-
ative pain be present, and several doses of pyram-
idon. In some instances, of course, spinal,
regional, or other form of local anesthesia is sub-
stituted for the gases, but the patient is never al-
lowed to remain completely awake. We believe it
more humane to carry out major surgical opera-
tions under general anesthesia if feasible, but it
must be remembered that an occasional goiter pa-
tient will seem on the verge of drowning in mucus
soon after gas is started. Just here the luminal
preparation has its particular value. Gas is dis-
pensed with, procain is injected, the operation pro-
ceeds with the patient rather oblivious to her sur-
roundings and later unable to state just what anes-
thetic method was employed. No doubt many
other similar emergencies arise touching every
part of the body. Atropin tends to rouse the
sleepy luminal patient if employed before an in-
halation anesthesia, hence its use is not to be re-
commended if it can be avoided. However, we
are frequently forced to employ it when an exces-
sive amount of mucus is secreted early in a thy-
roidectomy. Should there be actual need of pro-
ducing artificial sleep at any period of the hos-
pital stay outside the vital 36 anesthesia hours,
so-called, we resort to chloral hydrate and par-
aldehyde by mouth or rectum.
Our standard dose for strong patients in middle
life is 15 gr. of powder in hot milk, taken all at
once by mouth 3 hours before the operation, pro-
vided the blood pressure is not low. A very small
or greatly depleted woman takes less, and a very
large, active man needs more, as does one having
a toxic goiter.
A deep surgical inhalation anesthesia sometimes
seems more difficult to secure after luminal prep-
aration for the reason that a patient so treated
cannot inhale as deeply as would otherwise be
possible. This may possibly be a blessing in dis-
guise, so far as danger from the inhalant is con-
cerned.
The writers present a plan of anesthesia which
has been maturing during 10 years’ study on
selected patients; its conspicuous value in general
surgery has quite naturally suggested employment
in several other fields where a more or less com-
plete anesthesia is essential or at least desirable.
Hence the plan is amplified at this time in the
hope that it will meet the needs of most men who
comprise a general medical assemblage.
A perusal of German and French literature dis-
closes indications that barbituric acid compounds
neither slow up uterine contractions nor- poison
the fetus, hence one is inclined to believe that
this anesthesia plan might be of use especially to
the physician who has neither a hospital nor an
anesthetist. From the obstetricians we gather
that a multipara might average about 6 hours
and a primipara about 12 hours in labor; hence we
are advising that 3 gr. of luminal be given every
hour to the former from the onset of pain until 5
doses have been taken. The primipara might bet-
ter take 1% gr. every hour until 10 doses have
been used. For the actual delivery, a very little
gas or ether may be needed as is the case in major
surgery.
Dr. Tonelli tells me that a tonsillectomy pa-
tient under the influence of luminal is much more
manageable during the operation and preceding
nerve block than is one who has not taken the
drug. Further, it very greatly lessens the misery
of the first postoperative day although he uses
only one-half of our dose. Our wide experience ,in
general surgery has demonstrated that it may be
used in rather large doses without abolishing
cough, gag, or swallowing reflexes, a matter of
superlative importance since retention of these
I’eflexes constitutes the patient’s best defense
against lung abscess resulting from, inspiration of
infective material during or after a mouth opera-
tion.
Dr. Caulk feels that a field for this plan of semi-
anesthesia exists in operative cystoscopic work,
there being many such patients whom one desires
to make oblivious to their condition and surround-
ings for 24 hours following the procedure.
A 15 gr. dose of luminal goes far toward en-
abling one to make satisfactorily the type of
584
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
bimanual pelvic examination for which a general
anesthesia has been considered essential. In some
instances the woman retains no recollection of
what has transpired. The saving of expense and
the avoidance of risk are quite obvious. This plan
cannot, of course, be used in the treatment of
ambulatory patients.
Among the many highly disagreeable surgical
procedures is the induction of a spinal anesthesia.
We always prepare such a patient with luminal,
and then, provided the blood pressure has not
dropped too low, introduce the needle while she
lies on the side or on the face, depending on the
operation to be done.
Not all patients react alike to the after-effect of
luminal, hence postoperative treatment deserves
special consideration. The great majority of pa-
tients need no sedative after leaving the tab'e; a
very small second group which has been under-
dosed before operation is given luminal (1H gr.)
with pyramidon (5 gr.) every 4 hours as long as
restlessness or complaining continues, while mem-
bers of a still smaller third group become mildly
maniacal and require morphin (% gr.), after which
they act as do patients in the large group first
mentioned.
The actual results obtained in the treatment of
134 patients who received a single dose of luminal
are tabulated as follows — Effect upon reaching op-
erating room: slight, 13: medium, 87: profound,
34. The effect of the anesthesia lasted 26 hours
in the average individual.”
Intravenous Sodium Amytal
Reporting an experience of 200 surgical cases
in which complete or partial hypnosis was pro-
duced by intravenous administration of sodium
iso-amylethyl barbiturate, Floyd L. Grandstaff
(Am. Jour. Surg., 10:300, November 1930) says:
“In preliminary observations published by the
manufacturer, it was recommended that sodium
amytal in doses of 20 to 25 mg. per kilogram of
body weight be used for prolonged surgical anes-
thesia. In order to use sodium amytal as the
basal agent in anesthesia, this dosage was regard-
ed by us as the maximum. This was computed as
1 gr. per 10 lb. of body weight. We estimated that
temperature, thyroid dysfunction, age, develop-
ment, cachexia, dehydration, preoperative medica-
tion, type of operation, duration of operative pro-
cedure, etc., would alter the amount of sodium
amytal necessary to produce satisfactory narcosis,
and allowances were made for such factors.
Patients with hypertension and arteriosclerosis
were observed to react more quickly to sodium
amytal, and required less than patients having nor-
mal blood pressure. Obese patients required less
per kilogram than did lean or muscular patients
weighing approximately the same. An increase in
metabolic rate required an increase in the amount
of sodium amytal, and this was manifested in
adolescents who required more per kilogram of
body weight.
A decrease of 3 to 5 gr. of sodium amytal was
possible by increasing the preoperative morphin
from 1/6 gr. to *4 gr. Alcoholics, and patients who
had been receiving barbituric acid derivatives for
sleeplessness over long periods, required the maxi-
mum dosage. The average dose required for la-
parotomy was 11 to 13 gr.
The relatively small dose of 10 mg. per kilogram
of body weight, or 1 gr. per 20 lb. of body weight,
was used in combination with local anesthesia for
cystoscopy and nose and throat operations. In
these instances, the patients did not lose con-
sciousness, and they were susceptible to requests,
so that pyelograms were obtainable if desired, or
the patients were able to cough and raise mucus
or blood as the case might be. The patients would
often complain bitterly and appear rational, yet
none of them had any memory of painful exper-
iences.
Sodium amytal as dispensed, when mixed formed
a 10% solution. No solution was allowed to stand
for longer than 15 minutes before use, and a solu-
tion was discarded if not clear and cloudless. A
10% solution was injected intravenously not more
rapidly than 1 c.c. per minute. In cases in which
profound hypnosis was desired, the rate of in-
jection was decreased to 0.5 c.c. per minute as
soon as the patient became unconscious. A record
of systolic blood pressure, pulse and respirations
was made during each minute of injection and at
5 minute intervals throughout operation. It was
found that a decrease in rate of injection would
often control what appeared as a too rapid de-
crease in blood pressure. This was especially true
in cases of hypertension and arteriosclerosis. Hyp-
nosis was produced in the average patient in 3-5
minutes. The supplementary anesthesia consisted
of inhalation of nitrous oxide gas and oxygen.
Sodium amytal, as used in this series of cases,
did not produce anesthesia, but produced hypnosis,
and a supjilementary anesthetic was required. The
administration of sodium amytal produced a lower-
ing of blood pressure in all cases, and the decrease
was more marked in cases of hypertension and
arteriosclerosis. The immediate or remote effect
of the blood pressure change was not determined.
Relaxation of the throat and tongue produced a
temporary cyanosis unless closely watched and an
airway or Connell tube inserted. The shallow res-
piration and long period of quiet after operation
was credited with a tendency to pulmonary con-
gestion. Of the first 100 cases, 25% required
catheterization, but once the nursing staff became
accustomed to awakening sodium amytal patients
and encouraging them to void, the percentage was
no higher than after other general anesthetics.
Urine specimens of all patients were found to con-
tain acetone during the first 24 hours. Two pa-
tients manifested a bright red rash which dis-
appeared within 36 hours.
Postoperative complaints of nausea and vomit-
ing were absent in 95% of the cases. There ap-
peared to be less paresis of the intestinal tract
with consequent less pain from postoperative gas
pains.
The quantity of inhalation anesthetic was re-
duced. Amnesia without hypnosis was obtainable
and with local anesthesia was especially adaptable
to minor operations with special reference to cys-
toscopy.
Use of sodium amytal as the basal agent in
combination with inhalation of gas and oxygen,
with or without a preoperative dose of morphin,
produced satisfactory obtundation for all major
surgical operations, and was considered to have
many advantages not obtainable from other anes-
thetic drugs.”
Concerning intravenous use of sodium amytal,
Francis M. Findlay, reporting experiences at the
Cambridge (Mass.) Hospital (New England Jour.
Med., 203:1029, Nov. 20, 1930), says:
‘‘Intravenous anesthesia has been used abroad
for the past 10 years. It was first introduced in
France, later in Germany, and for the past 2
years has been employed in some of the larger
clinics in this country. Its use has been some-
what limited, as it has been regarded by many as
a rather dangerous drug. Our experience at the
Cambridge Hospital embraces a small but varied
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
585
series of cases in which the results were uni-
formly satisfactory, and I deem the drug of suffi-
cient merit to warrant reporting at this time.
We are not advocating discard of any of the
generally accepted anesthetic agents which have
been used so successfully over long periods
of time; we are simply offering our experience
with an anesthesia which we feel holds a definite
place and has made a distinct contribution to our
anesthetic equipment. The toxic effects of ether,,
particularly in debilitated patients, or in poor risks,
are too well known to discuss at this point. Local
anesthesia, well administered, has come to have a
definite place in the surgical field. Abroad, the
majority of surgical operations are done under
local anesthesia. In this country there is an in-
creasing tendency toward the use of local anes-
thesia, but many surgeons and patients object to
the mental strain to which the patient is subject-
ed because he is conscious. In spite of this fact,
local anesthesia has m,ade rapid strides and in
many clinics is employed by choice. With sodium
amytal supplemented by local anesthetics we feel
that we have an ideal anesthesia for carefully
chosen cases, particularly the aged and poor sur-
gical risks.
The only preliminary medication we have used
has been morphin sulphate, 1/6 or % gr., an
hour and a half, and repeated half an hour, be-
fore administration of the sodium amytal. We
have not wished to complicate the picture by the
administration of other drugs. In patients hav-
ing morphin, the anesthesia was pronounced and
of longer duration than in those without morphin.
Lundy, in the Mayo Clinic, advocates 10-15 gr. of
chloretone by mouth, 2-3 hr. before operation, fol-
lowed by a single dose of morphin, % -1 /6 gr., and
atropin, 1/150 gr. The average duration of the
anesthesia is from 40 minutes to 1 hour. The pa-
tient, at the end of this time, usually begins to
move and may make a few incoherent remarks,
but for the next 12-24 hr. generally sleeps quite
soundly. There has been no postoperative nausea
or vomiting in any of our patients.
With sodium amytal alone, without preliminary
medication, we have been able to obtain satisfac-
tory anesthesia for simple operations, such as re-
duction of fractures, curettage, rectal operations,
and simple operations on the neck, head or extremi-
ties. In combination with morphin, we have ob-
tained satisfactory anesthesia for a radical breast
amputation, appendectomy and hernia. In combina-
tion with spinal anesthesia, any abdominal opera-
tion that does not require over 40 minutes can be
readily done. Relaxation is complete, and the pa-
tient is entirely unconscious. From our experience,
we feel that the combination of spinal anesthesia-
subarachnoid block — as Labat terms it — with amy-
tal offers the ideal anesthesia in the poor risk. The
spinal anesthesia insures complete relaxation of all
muscles, while the amytal renders the patient un-
conscious and assures from 12 to 24 hr. postopera-
tive comfort. Mason and Baker feel that the chief
virtue of the drug is that it frees the patient from
mental strain and worry. We concur in this find-
ing but feel that the lessened shock, especially in
the aged and feeble, is the greatest contribution.
In 1 or 2 operations in which there was some de-
lay, it was necessary to administer novocain in-
filtration to close the abdominal wall, or supple-
ment the sodium amytal by gas or ether. In 2
cases we were able to perform radical operations
upon patients with hypertension and chronic ne-
phritis without any discomfort or injury. The pa-
tients require less postoperative morphin, as the
sedative effects of the anesthesia often last until
well into the next day following operation. Two of
our patients required secondary operations. Both
requested sodium amytal. We have had no deaths
attributed to the use of this drug. There were 2
deaths in this series of 30 cases, 1 in a cardiac aged
74, who died of cardiac failure 4 days after drain-
age of the gall-bladder; the second in a 92 year
old woman with general peritonitis, who develop-
ed a volvulus of the small intestine 10 days after
operation. It does not seem fair to attribute either
one of these deaths to the anesthetic. We have not
noted the bladder complications or pulmonary
edema which Mason reports. Certainly our pa-
tients have suffered less shock than those having
inhalation anesthesia. We have used the drug
twice to quiet excitable nonoperative patients. We
have used it once for a wildly excited alcoholic,
with excellent results. It is ideal for operations
about the head or neck, and wherever the cautery
or diathermy is used the explosion hazard is re-
moved.”
Current Events
TRISTATE MEDICAL CONFERENCE
The eighteenth session of the Tristate Medical
Conference was held Saturday, May 23, 1931, at
10.30 a. m., at the University Club, Philadelphia.
Those present were:
New York — William H. Ross, Brentwood; and
Joseph S. Lawrence, Albany.
Pennsylvania — Ross V. Patterson, Philadelphia;
William H. Mayer, Pittsburgh; Walter F. Donald-
son, Pittsburgh; Frank C. Hammond, Philadel-
phia; Harry W. Albertson, Scranton; Arthur C.
Morgan, Philadelphia; William T. Sharpless, West
Chester.
New Jersey — George N. J. Sommer, Trenton;
J. B. Morrison, Newark; Ephi'aim R. Mulford,
Burlington ; Henry O. Reik, Atlantic City.
Dr. Lawrence expressed Dr. Sadlier’s regrets at
being unable to attend the Conference. A tele-
gram containing Dr. Vander Veer’s regrets also
was read by Dr. Reik.
PROGRAM
Our Responsibility for Public Education Regard-
ing' Comparative Costs of Sickness
Ross V. Patterson, M.D.,
Philadelphia, Pa.
Our program is encompassed by 2 topics, but
they are related and I think perhaps it will fa-
cilitate the discussion if both presentations be
first made and the discussion follow. With your
permission we will proceed along that line.
In making my own presentation, I may say that
I have had in mind for some time the relation of
certain facts and studies that have been made
within the past few years with regard to the cost
of medical care, the cost of medical education, the
obligation of the profession to provide certain
medical service to the indigent and to those in
moderate circumstances. There has been a good
deal of medical discussion, a good deal of lay com-
ment, and I think there has been a good deal of
misunderstanding with regard to the purport of
certain facts which have been ascertained in va-
rious studies and of certain opinions that have
been expressed by leaders in our profession. There
is thought to be a need for public education. My
586
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
own feeling is that there is a greater need for edu-
cation of the profession itself and that public un-
derstanding will be the better when medical un-
derstanding of certain facts becomes clearer than
it is now.
Dealing with round figures, the national income
is about $100,000,000,000 a year and we have to
understand that fact in order to interpret the na-
tional cost of any activity or of any industry..
About $3,000,000,000 is the cost of medical care;
which is, of course, approximately 3% of the na-
tional income. That $3,000,000,000 is apportioned
to various bodies and activities concerned in medi-
cal care and, roughly, about !4 of that goes to
doctors; which is, of course, $750,000,000 per year
for the 120,000 practitioners in active practice — a
little over $6000 per year each. And yet studies
have shown that only about Vz of those physicians
make so much as $3000 per year. So, it is ap-
parent that the average doctor is not being over-
paid.
The hospitals receive about % of this $3,000,000,-
000 expenditure for medical care; that is another
$750,000,000; or perhaps a little more than that.
There are some 8000 hospitals in this country and
they have about 1,000,000 beds. I do not know
what they cost but the investment of hospitals
would certainly have to be $4000 per bed as a low
figure for construction cost ; which would mean
$4,000,000,000 invested in hospitals, and it takes
something less than $1,000,000,000 a year to run
them and some 500,000 people to carry on their
activities.
From the total expenditure for medical care
about $750,000,000 goes to the druggists, not only
for prescriptions but for all the patent medicines
and self medication of the people of this country.
Then the remaining $750,000,000 goes to dentists,
nurses and quacks. Flow there is, in round fig-
ures, our expenditure of $3,000,000,000 for medical
care; V\ to the doctor for division among 120,000
doctors; Vi to the druggists; !4 to the hospitals;
and % to the dentists, nurses and quacks. Even
these figures seem very large but their importance
is only to be estimated by comparing them with
other national expenditures. We learn, for in-
stance, that the salaries of railroad employees in
this country amount to $3,000,000,000 a year. That
is as much as is paid for all the expense of medi-
cal care, regular and irregular. The bootlegging
bill of this country is not less than $3,000,000,000
a year. The tobacco bill of this country : you know
in 1930 there were 120,000,000,000 cigarettes sold
in this country. That is 1000 for each man, wo-
man and child, and the cost of tobacco in this
country was about $2,000,000,000. Jewelry and furs
to the amount of $750,000,000, or the equal of what
is paid to the doctor. Perhaps we could consider
jewelry and furs as luxuries, yet we hear very
little complaint about the high cost of jewelry and
furs. There are $4,000,000,000 a year spent for
automobiles; that is more than the entire cost of
medical care. It takes $1,000,000,000 worth of
gasoline to run them each year, and that is more
than all the doctors get put together. The wo-
men of this country spend for cosmetics and in
beauty parlors as much as $750,000,000 a year — as
much as the entire country pays to all the doc-
tors. Now do not understand me as criticising this
expenditure. If it were twice as much I would
still approve of it. I believe it is a woman's duty
to be even more beautiful than nature has made
her, and if it costs many times that amount it
would be a proper expenditure. But, I merely
mention it in comparison to the cost of medical
care. When I make these comparisons it is seen
that the cost of medical care is not out of pro-
portion to other national expenditures. It is un-
fortunate that the public has somehow or other,
chiefly through what has been said by the medi-
cal profession itself, come to believe that it is
paying an excessive amount for the fees of the
120,000 doctors, for the hospitals which contain
1,000,000 beds and to which nearly 10,000,000 peo-
ple i>ass each year, and that it is paying too
much for all of these things. Now, as a matter
of fact, it is not. Calling attention to these
facts does not mean that we should not continue
to do what we can to lessen the cost of medical
care, and particularly for those who find the bur-
den heavy, but there is no good reason why the
doctor should disparage the value of his own ser-
vices or the institutions in which he works.
Now, what about the doctor himself? Well, we
hear a good deal these days about the excess of
applicants for medical schools, that there are a
large number of men seeking to get into the medi-
cal schools, and a large number are turned away.
Some who believe this to be the fact interpret
it as the endeavor of the medical profession to imi-
tate the methods of trade unions by limiting
those who may enter the practice of medicine.
What are the facts? Every first-grade medical
school in this country has a large number of ap-
plicants for admission; a number far in excess of
the number of places in the classes. If we take a
half dozen leading schools of this country they
will show 2000 or 3000 applications for every 150
places; that is 20 men for each place, and it seems
to indicate a tremendous number of applicants b -
ing rejected. Facts are that about 8000 men make
about 30,000 applications, and that 6000 of those
men are accepted and 2000 are rejected; % of
those who apply and complete their applications
find admission to some medical school — not neces-
sarily the school of choice. Of those 6000 men,
about 4500 are graduated; that is, Vi of the num-
ber are eliminated after admission to the medical
course.
It is interesting, in endeavoring to ascertain
whether or not the doctor is over-paid, to inquire
into the cost of his training. Those men who are
admitted to the medical schools are for the most
part college graduates. Some of them have had
but 3 years of college work, and a few of them are
admitted in some of the schools upon 2 years of
college work following the completion of a high
school course. If one estimates the cost of the
medical course itself, eliminating the expense of
the college preparatory course, he will find that
each student must spend a minimum in tuition
and in expenses of living, for books and instru-
ments, during the session of 8 months for 4 years,
not less than $5000. That does not include his
traveling expenses to or from the school. It does
not include those who are more liberal but it
represents about the minimum; $1200 a year is
about the least that any medical student can get
along with these days; $400 of that is tuition, and
the other $800 is only $100 a month for his board
and room and books. If one would add to that ex-
pense the value of his lost time, or what his earn-
ing capacity might be. one would say that a medi-
cal education would cost from $10,000 to $20,000,
eliminating the expenses of his college preparatory
work. He graduates at about the average age of
26, then takes 1 year or 2 in a hospital, and it is
2 or 3 years more before he is self-supporting. At
30 years of age he is just about prepared to sup-
port himself and to begin to be active in the prac-
tice of medicine. Now. it is an interesting fact
that if you would take the amount that his educa-
July. 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
587
tion lias cost and add to it the loss in earning
power, and put those sums together at the time
of his graduation and invest the fund at ordinary
6 Co compound interest, at 50 years of age he
would have a sufficient ,sum to maintain him for
the rest of his life. And yet, how many physicians
at fifty could retire? Is the doctor over-paid?
He most certainly is not, with an average income
of §6000 a year and fully half of them earning
only §3000.
There is one other thing that has been in my
mind for some time. I have noted on many occa-
sions a tendency on the part of the m'embers of
the medical profession, and often of its leaders,
to speak rather disparagingly of the work of the
medical profession, and of its accomplishments
and its attainments. Modesty is, of course, a vir-
tue but undue modesty may be a fault. How many
of us have heard physicians in public addresses
speak amusingly of the failures of the medical
profession, call attention to opinions which were
held 50 years ago that today seem ludicrous,
which, of course, is an easy way to get a laugh.
When I served on the Commission of the Healing
Arts, there were many, many times when the
chiropractors, osteopaths and other quacks con-
victed the medical profession of the grossest
blunders, of the most deplorable lack of knowl-
edge, from words taken out of the mouths of our
•own leaders. I believe that it is an important
thing for our medical societies to have in mind the
education of our own members, to enhance some-
what the self-esteem of the rank and file of the
practitioners of medicine. It is amazing how lit-
tle is known by members of our organization
about the history of medicine, its great accom-
plishments, its great names. There is too little
said about these things. I believe it would be a
good thing if every county medical society de-
voted one evening of each year to a program
which set forth biographic sketches of great medi-
cal men or dealt with great achievements in medi-
cine. These facts are too little known by the
profession, and they are almost totally unknown
to the public. For instance, the most recent bul-
letin issued by our Health Department, of Phila-
delphia, calls attention to the fact that in 1906
there were in the city of Philadelphia almost, not
quite, 10,000 cases of typhoid fever, and that last
year — 24 years later — there were just about 100
cases. I began the practice of medicine in Phila-
delphia in 1906, and when I saw this statement my
mind went back to the time when, as a young
practitioner, a considerable portion* of my practice
was made up of cases of typhoid fever. From a
pecuniary standpoint they were particularly prof-
itable cases, for typhoid fever is a disease of long
duration, of many sequels, and has prolonged con-
valescence; need for medical care continues over
a period of many weeks. From a pecuniary stand-
point the loss to the medical profession, incurred
by a reduction of typhoid fever cases from 10,000
a year to 100 per year, if worked out in figures,
would be stupendously high. And yet, how was
this brought about? By the profession itself; the
only profession in the world that seeks to reduce
the material upon which it depends for an exist-
ence. The public should be made aware of this
fact. First of all our own members should be
made aware of these and similar facts, and should
show pride in them and be prepared to defend the
profession against assaults by the ignorant, the
malicious and those who attempt to discredit our
importance and the value of our work. It would
be well, I think, to call attention to the uninter-
rupted existence of medicine — the oldest profes-
sion in the world, older than Christianity — going
back to Hippocrates, 400 years before Christ. At-
tention should be called to the great accomplish-
ments in surgery, in bacteriology, in preventive
medicine, and all such things. Get it into the con-
sciousness of all of our own members first, and
then the public may learn from them something of
our work.
A Romance of Paternalism
Walter F. Donaldson, M.D.,
Pittsburgh, Pa.
Tom Jones and Paul Smith, each aged 21 years,
graduated together from a Pennsylvania college
in June 1918, and immediately enlisted for service
in the World War. They remained in separate
training camps in the United States, and were
honorably discharged in improved health in De-
cember of the same year.
Jones entered a broker’s office, and 10 years la-
ter, at the age of 32, was prosperous and in good
health, except for an epididymitis, which devel-
oped in 1930 after an ardent but ill-fated affair
with a woman of easy virtue. Smith entered
medical college in 1919, and after the necessary 5
years of preparation and 2 additional but volun-
tary years of hospital training, began practice in
his home town, and in 1930 was chosen to be the
genito-urinary surgeon on the staff of the local
general hospital.
Broker Jones consulted Dr. Smith, his former
comrade in arms, regarding his infection, and Dr.
Smith advised an operation, to be performed at
the home town hospital, and plans were made ac-
cordingly. But an enthusiastic former comrade,
with a political slant toward special benefits, hear-
ing that Jones was hospital-bound, reminded him
that a vote-seeking' group of congressmen had re-
cently successfully piloted through Federal legis-
lation providing free hospitalization and treat-
ment for all former soldiers, regardless of their
ability to pay or the relation of their disability
to their war service. So, prosperous Jones, with
his impairment received in an affaire cl’arnour 11
years after his discharge from the army, was
transported, at government expense, to and from
a distant government hospital, while Dr. Smith
chalked up another fee lost, and the local hospital
another empty hospital bed, to the absolutely un-
fair paternalistic competition of Uncle Sam.
Who provided the cash to pay for Broker Jones’
free transportation, free hospitalization, and free
treatment? His former comrade Dr. Smith, his
neighbors who maintain the hometown hospital,
and others who pay a Federal income tax. Ap-
proximately 15,000 of the approximately 30,000
World War soldiers at present in recently built,
but frequently unnecessary, government hospitals
are being treated for ailments in no way related
to their army experience, and without considera-
tion of their financial ability to pay the charges of
hospitals and physicians adjacent to their places
of residence.
Was Jones, during his convalescence at the hos-
pital, much in contact with other patients — the
much honored and worthy beneficiaries of a grate-
ful government? No! Those today in government
hospitals surviving wounds and sickness or disease
actually related to war or camp service number
but 15,000, and they are often segregated from the
other 15,000 at present in , government hospitals,
who, like Jones, are receiving free treatment for
ailments in no way related to their army exper-
ience and without consideration of their ability to
588
JOURNAI, OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
pay for treatment nearer home. So, in company
with other country club members, who are conva-
lescent from tonsil or appendix operations, or from
an attack of gout or “nineteenth hole” neuritis,
Jones whiles a way a prolonged period of conva-
lescence criticising the wise President of the United
States, who successfully obstructed the passage of
legislation designed to extend the same econom-
ically unsound free hospital benefits to all the
members of the families of former soldiers. Of
course, Jones and the others wondered when an
ungrateful government would include free cloth-
ing and free shoes, or begin to transport its in-
dolent heroes to free hospitals built in Hawaii or
Porto Rico, rather than to those only 2000 miles
away from home.
After a stay in the hospital 3 weeks longer than
necessary, or possibly had Jones been paying for
it, (it is difficult to find enough patients to fill
the beds in many of the government hospitals)
Jones returned to his home town, where for a long
time he “groused” about the quality of the free
service he received from a bureau-controlled gov-
ernment hospital.
In the meantime, Dr. Smith having aroused the
interest of his fellow Federal income-taxpayers on
the board of directors of the local hospital, as well
as in the county medical society, is, or should be,
endeavoring to convince his congressman and the
senators from his state that the Federal govern-
ment must respect certain fundamental principles
of “states’ rights”, and abandon its policj’ of pro-
viding free medical and hospital care, and finan-
cial relief, for war veterans, except for impair-
ments which can be reasonably related to war ser-
vice, or the veteran who is unable to pay for treat-
ment. Dr. Smith contends that since physicians
represent the first group of citizens whose eco-
nomic welfare is seriously threatened by this form
of paternalism, and since they compose one of the
few remaining individualistic professions, it is the
duty of physicians to become politically conscious
and to take the lead in fighting for recognition of
“states’ rights” and for discontinuance of Federal
interference.
Those of us who retain knowledge of the mean-
ing and relation of such Victorian words or terms
as “pork barrel”, and “rivers and harbors”, to con-
gressional raids on the Federal treasury, will no
doubt agree that the large sums of Federal money
spent in a congressional district to “improve” the
harbor facilities of an erstwhile lack-a-daisical
creek or river, or to erect a post-office building
extravagantly large and ornate for the actual ser-
vice requirements, pale into insignificance polit-
ically when compared with the patronage possi-
bilities following upon success in landing a $2,000,-
000 veterans’ hospital for the “old home district”.
The initial investment may appear a paltry sum,
but the annual budget and the political strength
and patronage garnered in the influence of several
hundred hospital employees in a congressional dis-
trict may assure the fortunate congressman many
terms in office. Therefore, the Veterans’ Hospital
Racket is here to stay.
Surely, those who pay taxes to the United States
Government will not supinely continue to approve
free medical, surgical, and hospital treatment ol
the disabilities of -1,500, 000 veterans which origin-
ate as ordinary incidents of every-day life 12 or
more years after the World War ended. Congress-
men and Senators who support such legislation
must be rebuked at the polls, and the great ma-
jority of the veterans retaining their patriotic
principles must repudiate the noisy minority who
continue their raids on the public treasury.
An editorial writer in a recent issue of the
“Outlook" ascribes the victory in the passage of
the Johnson Bill to the "grasping element in the
American Region'’, and to “cheap politicians in
Congress who will oblige any vigorous minority in
order to be reelected”. The same writer describes
the bill as: “A grab, a gouge — nothing more.
Under the guise of providing for some meritorious
border-line cases of disability, it opens the door
for general pensions for everybody (4,500,000) who
wore khaki during the World War.”
“When the country adopted the War Insurance
Act in 1917, it was assured that the scandals of
the G. A. R. pension grab would never be repeated.
When it granted the bonus, it was reassured again.
The Legion itself went on record as opposed to
general pensions. Y'et, where are we now? Now
we have a brand new method of granting money
based on present-day accidents in civil life, and
having nothing to do with the war.”
With full knowledge of such facts, Calvin Cool-
idge said: “All countries on earth, in all history
all put together, have not done as much for those
who have fought in their behalf as our country
alone has done since 1880.”
It becomes hard for physicians to remember the
earlier resolve to support every possible form of
assistance to veterans, the victims of disease and
injury resulting from war service, when we look
on with righteous indignation while prosperous
veterans are treated, without cost, at government
hospitals, for civil life impairments such as en-
larged tonsils, while vacant beds remain plentiful
in home-town hospitals that are supported by the
same citizens whose tax money also pays for the
erection and maintenance of the already too nu-
merous veterans’ hospitals.
Apparently nothing can daunt the determination
of the American Legion and other veterans’ or-
ganizations in their relentless march toward big-
ger and better government aid for ex-soldiers. Fol-
lowing the recently enacted Federal legislation
making available the cash bonus will come the al-
ready announced legislative program for immediate
cash payment of all bonus certificates at their ma-
tured value. Who shall take the lead in devel-
oping resistance to this veterans’ pressure, in
shaming veterans out of such demands? If our
younger men are taught that service to their
country means that our Government thereafter
must reward them irrespective of their needs,
then we are indeed undermining the very founda-
tions of good citizenship. Veterans must develop
and manifest a? peace-time patriotism before the
burden of pensions becomes intolerable.
Our Civil War pensions, instituted in 1879.
amounted in the year 1919 to $125,000,000 or 4
times as much as they were 50 years earlier. If,
as was recently proposed by National Commander
O’Neil, of the Legion, the next Congress grants
equality of pensions for veterans of all wars, then
in a short time the Federal government will be
paying out annually to its more than 4,000,000 vet-
erans more money than we spent v’hile actually
engaged in the World War. A Billion Dollars a
Y’ear !
Dr. Smith, while agreeing that our Federal gov-
ernment should show’ every possible reasonable
consideration to our war veterans, also emphasizes
the fact that a larger proportion of physicians
entered government service in 1917 and 1918 than
from any other professional group. When the
proposed 47 or more veterans’ hospitals, each sus-
taining more salaried employees than patients,
have been completed and occupied, then will
“state medicine” have been thoroughly established
July, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
589
throughout the United States, never to be dis-
placed because of the political patronage involved.
And when veterans or their relatives no longer
abound, then will the free hospital service be ex-
tended to other citizens; and by 1960 the private
medical practitioner and the neighborhood hos-
pital may largely have passed out of the picture.
Think it over, readers or hearers of this basical-
ly true story. Discuss it with your tax-paying
neighbors, and with your congressmen. Any gov-
ernmental policy which decreases the present-day
attractiveness of medical practice to the intellec-
tual type of mind, and causes men of ability to
forsake it, is certainly against sound public policy.
Xone can successfully deny, it is believed, that the
Federal government, by the policy herein com-
plained of, is in unfair competition with private
physicians and the supporters of local hospitals
who in turn are taxed to finance this paternal-
istic, bureaucratic form of medical and surgical
hospital and dispensary practice.
Discussion
Dr. William H. Ross: Both of these papers are
so true and unquestioned that I can do nothing
more than endorse them. It seems to me just at
this moment that I have never heard any clearer
presentation of 2 problems, the need of education
of our own men, and the need of doing something
about the increasing paternalism. Just how to do
it is a. little more difficult to state clearly. The
suggestion that we should educate our own men
through our county societies is undoubtedly ex-
cellent.
The remedy, medically, is to endeavor to estab-
lish leadership by our own people. I think that
we are too modest in many respects. If we do not
assume leadership it will be done for us.
Some increase in state medicine is rather inevit-
able and we can only minimize it by our own lead-
ership. Some solution of the problem must be
found and I do not know, after considerable study,
more intense study than I have given to anything
else, whether health insurance is not the solution.
They have some forms of insurance in Europe that
have not destroyed the medical profession. The
average income of the physician in Denmark is as
much as it is in this country. There, they hold their
own because they are well organized; every doc-
tor must belong to the Medical Association of Den-
mark; their graduates are all of one school; 80%
of the population is insured. It is voluntary in-
surance, the government does not dictate the pol-
icy, and they have gotten along very well in meet-
ing their social conditions. I believe that we must
awaken to this one thing — that we must take
leadership — and that does not mean that we shall
change things very rapidly, but the influence of
things that we do today will be of 2 kinds; one
is the obvious thing that we can do, and the other
the intangible influence which will be producing
results even when we think it is not acting at all.
Dr. William T. Sharpless: With regard to Dr.
Donaldson's paper. I accept it in full. I think it
is a very good and timely presentation of the case
and it ought to claim our interest and our action
politically, as he suggests.
With regard to Dr. Patterson’s paper, I cannot
get all those figures in my mind. 1 hope that will
be published and that we will be allowed to have
an opportunity to digest it and work it out for our-
selves.
I noted in a recent Bulletin of the American
Medical Association a proposition to standardize
specialists. Specialists get large fees: general
practitioners do not, though they are largely the
feeders of the specialists. If the value of services
by general practitioners was more fully recognized,
I think it would make matters more satisfactory all
around. Recently, for instance, I had a patient
with cataracts. She was operated upon by a Phila-
delphia specialist. She is a person of moderate
means, but she received a bill of $1800 for the
operation. She has only 10% vision in the eye
operated upon, and he now wishes to operate on
the other eye. That is the kind of medical charge
that seems to me unfair.
I would like to see all the specialists standard-
ized, for many people are posing as specialists who
are not qualified but who advertise themselves, in
one way or another, as specialists and charge
large fees which they do not earn.
Dr. Joseph S. Laivrence: I wish that Dr. Pat-
terson had taken a few minutes more to suggest
at least one solution for part of the problem which
he has so ably described to us. I am convinced
that the one thing above all others that the medi-
cal profession is lacking in today is self-confidence.
The average doctor trembles at criticism by the
public health nurse regarding his methods of diag-
nosis or treatment, and yet she doesn’t mean to
be unkind but is simply expressing what she has
been thoroughly saturated with ; i. e., that medicine
is advancing so rapidly today that the m,an who
is out of college for some time is obsolete. If I
may draw upon my imagination to characterize
medicine today, I would say that we are in the
machine age, the time when a man’s material
equipment counts for more than his mental equip-
ment. Unless laboratory procedures, some very ex-
tensive and complicated, are called upon to assist
in diagnosis; unless a man’s office is equipped with
very impressive and expensive machinery; he is by
many people considered not qualified to practice
medicine. A portion of this feeling is due to the
efforts of those public spirited people to bring to
the people the best that there is in medicine, as
they understand it, and not having been medically
trained they do not understand medicine as physi-
cians do. They rather look upon health as some-
thing that can be rationed out as food and cloth-
ing were in the army. I think that is one reason
why the Legion succeeds as it does with Congress.
It makes the people believe that medical care is
something the soldiers had in the army; given to
them as part of the equipment which the govern-
ment issued to its soldiers in order to make them
as nearly perfect as possible; and now that they
are ordinary citizens, should not be denied them.
We are living in a time when many people believe
that medicine, or medical care, is something that
should be bestowed upon the public, rather than
that the people should know that there is avail-
able at any time this scientific knowledge. People
are not taught to seek their doctors for informa-
tion but are told that medical advice or service
can be secured at such and such a place and that
they should seek it there. I think it is a reason-
ing of this kind that is fostering health insurance.
In my opinion, the public is certain to be disap-
pointed later.
Dr. Arthur O. Morgan: It is seldom that one
hears a presentation in such clear-cut manner as
the 2 speeches we have had today. I happen to be
a member of the Committee on the Cost of Medical
Care, whose Chairman is Dr. Ray Lyman Wilbur,
and last week we had a 2 day session that was at-
tended by 50 of its 54 members; absentees were
either sick or out of the country — which indicates
the intense interest that is being taken all over
the country in this very vital subject.
Truths are taught by contrasts. Dr Patterson
590
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
has shown us, by contrast, the part that we of the
medical profession play in the economic life of
this nation. Our studies in the committee will
give you amplified information from many angles.
Dr. Patterson has likewise told us of the difficul-
ties now attendant upon teaching medical stu-
dents. If I may make the charge, I would say
that many medical teaching institutions are be-
coming too specialized. They are concerning
themselves too much with the ultra-research men.
The Johns Hopkins University, Duke University,
and the University of Rochester, are ultra-spe-
cialist institutions. I am pleased to state, and,
thank God, that the Medical College of Albany is
training general practitioners. There is your con-
trast. There has been too much of the fetish in
recent years, in respect to training specialists, the
fault for which lies largely in the faculties of the
various medical schools of this country, which
consciously or unconsciously create and set the
pace for the young men and women as they go out
into medicine. Dr. Patterson pleads for education
of the doctors. I plead for education and enlight-
enment of the medical faculties. Dr. Wilbur has
pointed to the threat of state medicine but he al-
ways has emphasized that the family doctor is the
key-note to the situation. In our work at Wash-
ington we have the very valuable aid of many
economists who are helping us to solve this prob-
lem of the cost of medical care and. to resolve it
into an economic picture which can be presented
to lay people. The doctors cannot put the eco-
nomic aspect of medicine before the lay people;
economists can, and that will be one of the major
accomplishments of this committee.
There are many magazines today eager to ac-
cept the specious statements, the “sounding brass
and tinkling cymbal’’ of men and women who
write for money, who can catch the eyes and ears
of the public, and that is why we are having- so
much criticism of the medical profession ; because
editors of such magazines accept that tinpan stuff
as presented to them, and which they think
pleases the reading public.
Dr. Donaldson is to be commended in highest
manner for his clear-cut presentation of a truth.
I am a member of the American Legion. I have
never been affiliated with the Veterans’ Bureau,
and have never been bound by any medical group,
so that all the time I have been a free lance, and
sometimes I have had the temerity to say things
which brought forth criticism from others who
would like to have said the same thing if they
had dared. The American Legion seems to have
gone wild in respect to wanting something for
nothing, and especially on this matter of present
day pension grants. Personally, from examining
boys who were in the war and who have been re-
ferred to me, I am firmly of the belief that many
of these boys have lost their American backbone
and have become sycophants because they think,
as Dr. Donaldson said this morning, that a pa-
ternalistic government will take care of them.
They want also to have their families cared for.
If the tide is not turned, there is no telling what
will take place in time to come, simply because
the “loud noise” and not the “best element” is in
the saddle.
A word as to Workmen’s Compensation and
State Medicine, for the first is here and the second
is in the offing. Workmen’s Compensation has
accomplished great good for the working man,
but when the Act was put over in Pennsylvania,
the medical profession was not awake to its op-
portunities and privileges and the result is that
under that law the physician has not received his
right as measured by dollars and cents.
Dr. Ephraim. R. Mulford: I unfortunately got
into contact with a bus and automobile accident
coming down the road and missed hearing Dr.
Patterson’s paper and got only a part of Dr. Don-
aldson’s splendid essay.
It seems to me that education is the power that
must turn the tide which now seems to be sweep-
ing over the country and leading the public to be-
lieve it can get something for nothing. Being a
general practitioner in a small town, it does not
seem to me that we will ever be able to do with-
out the family physician. f
I)r. Wiiliam II. Mayer'. It is difficult to dis-
agree with either of the essayists, and I certainly
pay high tribute to the excellence of their pre-
sentations. The man on the firing line determines
the efficiency of the army. So it is with the gen-
eral practitioner in his ability to apply his art of
medicine. Certainly the strongest link in the chain
of medical practice is the man who first sees the
patient and who has an intimate contact with him
and his environment.
I was struck by what Dr. Donaldson said about
political patronage and the necessity to fill the
government hospitals and to extend the number of
people in them. This is so clearly the problem
which we see with social work in the large cities,
where to get everything at any cost is part of
their work and they do it at the expense of the
morale of citizenship. I feel that we have a big-
ger and greater duty to humanity than simply the
question of preventing illness and curing sickness.
The citizenship of this country is one of the prin-
cipal factors of its constitution and when we al-
low our people, either through governmental agen-
cies or through the mass influence of the Ameri-
can Legion, to fail in recognition of responsibility
for preservation of their own health, then we are
helping to vitiate citizenship. We are allowing
certain agencies in this country, with a paternal-
istic spirit, to remove the backbone from our citi-
zenship. From a sociologic standpoint, this is an
important public matter. There is a group of phy-
sicians who feel that they have no responsibility
for public medical service; thinking it demeans
them, destroys their self-esteem, and blows up
much that has been constructed in a free country.
If we allow the people to feel that they do not
have to pay for medical care, the same as they
have to pay for insurance on their household
goods, then we have done an irreparable harm to
the constitution and to the morale of our citizen-
ship.
Dr. Patterson said that % of all the money ex-
pended for medical care goes to nurses and drug-
gists. There is a big problem before us in regard
to this. The use of prescriptions for certain kinds
of drugs approved by the American Medical Asso-
ciation is something which appeals to the general
mass and to the individual who indulges in self-
medication at the drug store. In regard to allonal,
for instance, these tablets cost the patient 10 cents
a piece. For every tablet made the man who has a
patent on allonal receives 1 cent. The cost of
manufacture is probably about 1/32 of a cent. The
use of such tablets by more than 100,000,000 peo-
ple amounts to an enormous sum. I have been
told that the man who makes allonal tablets was
once a poor chemist, but that he has become a
rich man. While I haven’t any objection to a man
becoming wealthy because he has chanced upon
something of this kind and has shown some gen-
ius, yet I think the American Medical Association
should, when approving such drugs, retain some
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
591
control over a reasonable sale price. That may
seem like going a little too far socialisticaliy, but it
is not. If these people are going to use their dis-
coveries to exploit sickness, they should not re-
ceive our support. I have only cited this one in-
stance but there are a dozen others. A few years
ago we were prescribing aspirin. It was a good
way to administer salicylates without upsetting
the stomach. Today, aspirin tablets are mixed
with bathtub gin to increase intoxication, and even
Amos and Andy are talking about it. All that
adding materially to the sum of what people pay
for sickness.
One other thing in regard to nursing costs. The
nurses do not get more than they are worth but
the individual often pays more than he can af-
ford. Here is a point that should be considered,
and I am sure the Committee on the Cost of Medi-
cal Care will feel that it is diplomatic to put some
reference to that subject in its report.
Dr. Harry W. Albertson : When I received the
program from Dr. Reik I wondered what could
come out of it that would be interesting to 3
states, but I want to say now that I think this is
one of the best programs I have listened to ini at-
tendance at these Tristate Conferences. I must
also say to the Chairman that he was extremely
modest in his assertion that $7-50,000,000 were
spent annually in cosmetics, because it was re-
cently brought out by a convention of beauty
specialists in Chicago that $3,500,000,000 were thus
spent; which is greater than all the costs of medi-
cal care.
I was impressed last night, on picking up my lo-
cal newspaper, with the inefficiency of the busi-
ness side of medical practice. A man in my neigh-
borhood, reputed to be wealthy, died recently, and
I noticed in the statement of settlement of his
estate that his doctor was paid $4000, covering a
long period of illness, and his attorney’s fee for
work during 5 or 6 weeks in settling the estate
was $6500. That is just an example of how quick-
ly men with business ability get money, while doc-
tors who spend a long time and much patience get
little in comparison.
I want to disagree with Dr. Lawrence, while I
have much respect for his opinion and his knowl-
edge of the medical profession generally, regard-
ing the statement that we are in a machine age.
I had this forcibly brought to my mind a few days
ago. I had occasion to call upon 2 doctors, both
good fellows. The office of one was composed of
a suite of 4 rooms, 3 of which were filled with
machinery, and his waiting room held 3 patients.
The other man had but 2 rooms, meagerly furn-
ished, but there were so many patients in his
waiting room that there was not room to sit down.
That man is a very careful practitioner, a man
who makes a study of every case and goes into
the intricate problems, and whose work is most
satisfactory. Unquestionably we need to have the
medical profession look to its business ability, and
I believe with Dr. Patterson that in educating our
younger professional men to realize that typhoid
fever and diphtheria were such large factors in the
general practitioner’s income 25 years ago, he will
understand that medicine has done something and
stands for something accomplished. Also we should
get it across to the people who are thinking dis-
paragingly of the medical profession.
I admire Dr. Donaldson for the stand that he
has taken on this matter of paternalism. It re-
quires a good deal of nerve to bring forth a prop-
osition which affects 4,000.000 men. 4,000,000 voters
in this country. I sincerely wish that we were
able to get that matter out of politics, that we
were able to educate a great majority of those
men to the fact that there is something more to
patriotism than that which they get for the ser-
vice they rendered.
Dr. Georye N. J. Sommer: I was very much in-
terested in Dr. Patterson’s discussion of the cost
of medical education. 1 recall that it cost my
father about $400 a year to educate me in medi-
cine, and it is costing me $2500 a year to educate
one son at the present time; so I can readily ap-
preciate the difference between the costs of 40
years ago and now. There are so many side is-
sues that enter into the education of a young man
today which did not exist then, and it is these
Side issues of a social nature that really cost
money.
I believe that we are largely responsible for
some of our difficulties. Our lack of success, in
the main, is due to lack of business education, for
the principles of success in medicine are the same
as in any business. You have to sell yourself as
a business has to sell itself, and the men in our
profession who have made good have been fel-
lows who w~ere not only skilfull and capable but
who also were able to sell themselves to the com-
munities in which they practiced. I feel that my
own success has been largely due to the fact that
I could sell myself to my patients and make them
feel that they are getting from me a square deal.
If I have accomplished anything in the practice
of medicine it is because I have held true to medi-
cine and not permitted myself to be diverted by
other things. I started out to be a physician and
hope to remain one as long as I live. I have not
been a politician nor tried to mix much with pol-
iticians, but this fact remains — that if I want
something for my friends, from politicians, my
reputation as a physician and citizen in my com-
munity enables me to get it.
Dr. J. B. Morrison': I think the papers we lis-
tened to this morning give us some very basic
ideas to carry back to our county and state so-
cieties. The conclusions that will be drawn from
the report of the Committee on the Cost of Medi-
cal Care must be promulgated through our pro-
fession to the people in such way as will make
them realize that of the total cost of medical care
the portion paid to physicians is probably less
than it should be. I make it a practice, whenever
opportunity offers, to speak of this subject to my
patients. In such a conversation last week with
a man and his wife I gave the figures which Dr.
Patterson presented today and showed the small
returns to physicians relative to the amount of
labor performed and the value of lives protected
in the community. The wife said that those fig-
ures are excellent and cannot be disputed when
you speak of the people as a mass, and of the ser-
vice of the medical profession as a mass, but when
you come to an individual it is different. She said
her sister had a child operated on for mastoiditis.
The father earned $2500 a year and the bills from
the hospital and surgeon were $750. I reminded
her that her doctor’s bill was only $150 and that
the hospital and nurses received $600. Then I
said: “M'y dear woman, you and your husband
have no right under our present economic system,
nor your sister and her husband, to spend on the
care of that child $750 for a mastoid operation.”
She had no moral right to put that child in a pri-
vate room and require 2 private nurses unless the
doctor demanded it. The fault is not with the
medical profession nor with the hospitals but it is
that the people of the United States have forgotten
what economy means, and they must give the best
to their children and indulge in luxuries that only
592
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
a person with an income of $25,000, instead of
$2500, could have. If the child had been treated
in the ward, the result would have been the same,
and if a private nurse had been necessary she
would have been supplied. The child could have
been brought back to health for half of the money
spent, and neither the medical profession nor the
hospital should be criticised for what was con-
sidered an enormous bill.
We must drive this teaching- home to patients
whenever possible. It is easy enough to make
them understand that the fees are not exorbitant
except in certain lines of work.
The matter of carrying this to the public be-
longs, I suppose, to the profession, and it will
never be done in a satisfactory way until it is tak-
en from the hands of the individual physician and
done as a business policy by the state societies.
1 believe that if every state society in the Union
were to follow in the footsteps of New Jersey, and
spend $10,000 to $15,000 a year to carry this edu-
cation to the public, spend from their own funds
for this educational campaign, it would be money
well spent and the results would be found as suc-
cessful as we have found them in New Jersey.
This is legitimate advertising; and the business
man realizes that returns from his business are in
direct proportion to his advertising.
I heartily agree with what Dr. Donaldson has
said in his paper. I happened to be in Washing-
ton during the debate on payments to soldiers on
their Bonus Bill allowance and I sat in the Sen-
ate on the evening when the vote was taken. I
heard 2 Senators, members of the Legion, criti-
cise that Bill very severely, expressing the opin-
ion that there was a large group of veterans who
did not want legislation of that kind, nor be-
lieve these favors should be given them by the
Government. But, the argument was lost and the
vote was overwhelmingly in favor of the bonus,
because the politicians were able to make political
capital of it. Whether or not 150,000 physicians in
the United States can organize and stop this thing
is questionable. Perhaps, given 10 years time, with
an organized effort and the matter put into the
hands of committees to work judiciously, we might
be able to influence public opinion but I do not
think we can do it as fast as it is being created in
the opposite direction. I have been rather severe-
ly criticised in New Jersey because of my stand
in the discussion of state medicine. I have taken
the bull by the horns, and brought the matter to
the attention of many of the county societies. I
believe the time has come when we must realize
that state medicine is more than a possibility. For
a while we were buoyed up by an idea that it was
un-American, that the living wage was so high
that state medicine could never gain a foothold in
America, but in the provinces of Canada where
the people are of English. Scotch. Scandinavian
stock, where the immigration has been markedly
restricted, where they probably have not 1/10 as
many people from the Slavic races of Europe as
we have in America, where the earning capacity
of the average citizen is about as much and where
the independent spirit is just as great, state medi-
cine is making enormous strides and it is antici-
pated by some leading physicians that in less than
5 years it will affect every province. Canada is
my native home and as we travel through Canada
the only difference from the United States is the
fact that we live under a different flag. Now, if
they are solving their economic problems in that
way it will be brought to the attention of the peo-
ple of the United States very soon and my plea is
that in every state society a committee shall make
a study of this matter and be able to present to
the Government at the proper time a plan to avert
or guide state medicine, and prevent its being
crammed down our throats. A comparison with
Austria and Germany shows that the organized
efforts of the French physicians wrested from their
Government plans that were 50 times more favor-
able than those in Austria and Germany.
Will state medicine get here? We do not know,
but if it is in the offing it will do us no harm to
make this comprehensive study of the matter and
be prepared to meet it when it comes. It will in
all probability only apply to those earning under
$2500 or $3000 a year. Others will want to retain
their independence and have their family physi-
cians just as they refuse now to accept charity in
hospitals because they want to pay their way. So,
you need not fear that state medicine will ever at-
tain here the volume or proportion it has in East-
ern countries. There are several methods of ap-
plying it. If the Government starts it, there will
likely be a tax on our income. If it is done along
the lines of compensation, labor will pay part, the
Government part and the individual a part. But,
with a people as independent as ours, there is no
reason why it should not be carried by voluntary
insurance just as we do with life insurance. The
average outlay in a family is from $60 to $80 for
the year’s service and it can be readily seen that
by the payment of $S0 or $100 a family can be
protected and funds established to meet an emer-
gency. Even those families in America who run
on a budget make no allowance for the medical
or surgical care that may be imposed upon them,
and when an emergency comes they must go to a
loan association and borrow money, at 12 to 36%.
I feel that in all our states a careful and com-
plete study should be made and plans organized
whereby we can offer the Government a solution
that will be favorable to the people and the doc-
tors.
Dr. Henry O. Reik : I want to begin by thank-
ing you. Dr. Patterson, for the suggestion that the
county societies should be urged to devote at least
1 meeting a year to the subject of medical history
or biographies of medical workers. We shall re-
commend that back home and see if we cannot
put it into effect next year. We have had- some
papers on the history of medicine published in the
Journal and are at the present time much inter-
ested in studying for publication the history of
medicine in New Jersey.
I was interested in Dr. Sharpless’ comment, call-
ing your attention to a resolution that will be in-
troduced in the House of Delegates of the Ameri-
can Medical Association regarding the control of
specialists and specialism. Of course, you are all
familiar with the Presidential Address of Dr. John
Hartwell, before the Academy of Medicine in New
York, and the effort the Academy is now making to
classify its members. Dr. Hartwell addressed one of
our Councilor District meetings recently on that
subject, reported the progress of the work in New
York and expressed the hope that it would be tak-
en up elsewhere. Our Second District had that
topic up for discussion and I learned from a report
of the Secretary of that gathering that they pass-
ed a series of resolutions to be submitted at the
meeting in June, recommending that the State So-
ciety put into effect a plan like Dr. Hartwell pro-
posed in New Y’ork. The resolution that is to be
introduced at Philadelphia by one of the repre-
sentatives from Michigan will, I presume, come
before the House of Delegates for action and I
wanted to ask whether or not the Pennsylvania
and New York delegates have taken any action
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
593
upon that resolution, and if you know whether
it is contemplated to approve and support it or
whether there is going' to be opposition to it ? The
question may come up at Asbury Park, as to
whether our delegates shall be instructed. If we
could ascertain today the position of New York
and Pennsylvania regarding that matter, perhaps
the 3 state societies can act in unison.
Several speakers have referred to the public
educational work. Of course, that is a topic in
which I am vitally concerned. W e have all read
with interest, sometimes with provocation, some-
times with disgust, the articles that have been
appearing in the newspapers and magazines. I
believe I have only seen two answers published
through the magazines, one by Dr. Johnson some-
time ago and the one by Winford Smith in last
week’s Saturday Evening Post. I want to ask the
question, to what extent you think we should go
in trying to get publication of answers to those
criticising articles. Is it a wise proposition to
secure, and seek publication of, answers to such
articles through the same magazines? For in-
stance, if we could get an answer published in the
Saturday Evening Post to some of its preceding
articles, either along the same line or going fur-
ther than Dr. Smith did, because in his article he
only answered a few points and not those for
which we have been most criticised. I once tried
to get an answer published in the Forum but the
editor answered my letter saying that he could not
allow the magazine to pursue a controversial ques-
tion. That, mind you, after he had published one
side of the controversy. Is it, possibly, a better
policy to ignore such things?
In the matter of public and professional edu-
cation, I am much more puzzled as to how to pro-
ceed with the medical profession than with the
public. It is much more difficult to get the subject be-
fore them properly and have it read. Dr. Ross has
had an experience this winter, and I can see it
in his remarks, about the question of state medi-
cine. During the past 4 months one of my own
articles has ben published in sections, intended to
give an account of the progress of national health
insurance laws in Great Britain and France, as
observed in my travels, and then such information
as I could collect from literature regarding other
countries. I have been a bit afraid of one result,
that as soon as a medical man reads an article
of that sort, and you have presented the facts
to him, he jumjps at the conclusion that you are
supporting the idea of state medicine. I very
carefully stated each time, and wrote accompany-
ing editorials on the subject, that I was not ad-
vocating state medicine but merely trying to lay
the facts before them so that they could prepare
for action, either to forestall it or to meet the
situation when it does arise, but I hear that some
readers have accused me of advocating state medi-
cine. That sort of misconstruing things makes
educational work extremely difficult.
Dr. Walter F. Donaldson (Closing) : I may men-
tion in passing that this is Dr. Mayer’s first ap-
pearance at one of these conferences and he may
understand now why former state society presi-
dents continue to attend these meetings years af-
ter they have ceased to serve as active officers.
They are welcome, of course, to continue as a part
of the organization, but I think their constant at-
tendance is due to the protean character of the
discussions; we are not limited in our discussions
to the specific subject announced.
As an evidence of how close we may be to state
medicine, I want to mention briefly a point re-
cently brought out in Pittsburgh by a public
health officer. He mentioned the fact that it would
be only necessary to introduce 2 or 3 words into
the Workman’s Compensation Act to bring about
state medicine; they would only have to make
that law applicable to illnesses as well as to in-
juries.
If the editors who are here today will adopt the
suggestion that has been brought out in Dr. Pat-
terson’s presentation, and put in parallel column
form the contrasts of what the people of this
country are spending on tobacco, cosmetics,
and movies with what they are actually spending
on doctors, hospitals, nurses and dentists, it might
make very instructive reading and would be dig-
nified enough propaganda to be hung in the
average doctor’s reception room. I see no rea-
son why a few facts of that kind, arranged in
parallel columns, appropriately framed, should not
decorate a doctor’s reception room. I would start
the pace and hang one in my reception room if I
had it, so I challenge you editors to get to work on
this.
The problem involved, in extension of the de-
sire to get something for nothing, is one that we
must consider not only as physicians but as citi-
zens. Senator Reed, of Pennsylvania, recently ex-
posed a situation in Washington in which he
pointed out that some 6 or 8 men, dentists, physi-
cians and attorneys, who were drawing maximum
pensions from the Veteran’s Bureau, about $250 a
month, because they were supposed to be completely
disabled and theoretically, at least, unable to sup-
port themselves, were also drawing salaries from
that same bureau ranging from $5000 to $8000 a
year for services rendered. There we have it in
high places. How in the world can we blame the
ditch digger or the man who cuts lawns for ask-
ing if he may be pensioned $10 or $20 a month
merely because he patriotically served his country,
when we have men of type mentioned accepting
more.
We are still an individualistic group and I be-
lieve we must when necessary put a little bit of
sting into our criticism and discuss pensions with
our neighbors. When you see a prosperous neigh-
bor go off to a Government hospital to receive
service, make him realize that your taxes are con-
tributing to his up-keep while the neighborhood
doctor and hospital are suffering because of his
action. It is only a question of time before we
shall have this tremendous financial burden con-
fronting us.
Dr. Foss V. Patterson (Closing): If I may have
an opportunity to bring the discussion to a close
I would add briefly to what I have already said
and perhaps emphasize the main point that I en-
deavored to bring out. In the first place, let me
say that the figures which I offered on the cost of
medical care were exclusive of governmental and
state agencies with which Dr. Donaldson’s paper
concerns itself. Let me say again that the $3,-
000,000,000 expended by this country for private
medical care constitutes 3% of our national in-
come, and that it covers the entire cost of the ser-
vices of physicians, hospitals and drugs prescribed
by physicia.ns, and prescribed by patients or sold
over the counter, and of dentists, nurses and
quacks. Now, if my arithmetic serves me correct-
ly, 120,000,000 people spending $3,000,000,000 is $25
each per annum, and $4 of that goes to the doc-
tor:. that is $6.25 per annum from each individual
in this country goes to the physician.
Figuring it another way, if the physicians re-
ceive $750,000,000 and there are 120,000 of them,
that is $6250 average to each physician; and it
checks one with the other.
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
594
There is still another way: If there are 120,000
practicing physicians in this country treating 120,-
000,000 people, that is 1000 persons for each phy-
sician. and if they pay $6.25, that is $6250 for each
physician or $6.25 each. Now, when we reduce
these figures to an analysis of that sort it becomes
apparent that the physician is not being over-paid,
and that the cost of medical care in this country
is not disproportionate to other expenditures. That
does not mean at all that there are not inequalities,
but, speaking in terms of the average, the situation
is not fundamentally wrong. If it is fundamentally
wrong, it is because the physician receives less
rather than more than he should get. The average
income of dentists is greater than that of doctors.
Now, is not the solution of the burden of medical
care, as pointed out by Dr. Morrison, first of all,
education of the profession itself as to the dimen-
sions of the problem, and then to pass that on to
their families and have families budget medical care
just as they budget their other expenses of rent
and coal and food and amusements and clothes,
and if on the average each family sets aside $6.25
for each member it covers the average cost of the
doctor’s fees, and if $25 is set aside for each mem-
ber it covers the cost of all medical care. If we
come to the panel system of state medicine, we
can easily figure what the return of the doctor
should be provided his income is not increased.
It amounts to $6.25 for each physician per indi-
vidual per year, or $25 for each member per an-
num to cover the entire cost of medical care.
Dr. Sharpless asks how we are to get at this.
It seems to me there are various ways of getting
this conception of the relation between medical
institutions and the physician to those for whom
they care. Certainly it should start in the medical
schools. Perhaps you would be interested if I told
you what I have personally endeavored to do in
this matter. Some 7 or 8 years ago a student
medical society was organized in the institution
with which I am connected. It has 28 members
made up of senior students. There are 7 meetings
a year. 1 each month except the last month of the
session. At each meeting 4 students present pa-
pers. That means that in 7 meetings all 28 mem-
bers of the society present papers. Those papers
deal with the history of medicine, with the epochs
in medicine, with great medical figures, so that
each student prepares 1 paper and hears 27 other
papers of 20 minutes length. At the end of the
year I believe that those 28 men have had a be-
ginning in education as to what medicine is, what
its history is, and what it stands for. They have
had the inspiration of hearing of the great ac-
complishments in medicine, and we follow some-
what a chronologic order. We may start with
Hippocrates, then we come down to notable fig-
ures like Tenner and Harvey and men who have
made great discoveries or great contributions. I
think it is proper that such study should begin
in the medical schools, and should be extended to
include the entire student body. My own oppor-
tunities at the moment seem to be limited to this
particular group. You know some of the medical
schools are establishing Chairs in Medical His-
tory. and I feel that the value of that would be to
inculcate into the graduates a proper apprecia-
tion of medicine.
The second great opportunity is in the hospitals.
Of the 120,000 physicians in this country, 90,000
are connected with hospitals. Why is it not proper
for hospital staffs to concern themselves with this
side of medicine?
Dr. Sommer liaised a point in regard to the art
of medicine. Under our system of medical edu-
cation today the hospitals become a part of the
medical educational system. The function of the
medical schools is to train men in fundamentals.
The function of the hospital and its staff is to
train them in the art of medicine. If they lack
in the art of medicine it is chiefly because of a
defect in hospital training. If the members of the
hospital staff could be brought to an appreciation
of their responsibilities it would tend to elevate
our ethical standards in medicine, and why should
they not concern themselves with the ethics, with
ihe history of medicine, first applying it to them-
selves and meeting once a year with the interns,
perhaps having the interns themselves prepare
papers? It can be done and it is easy enough to
do. My experience with these senior students has
been surprising. Some of their programs would
be admirable programs to present at county medi-
cal societies. They would be instructive and the
members would be interested. I am glad that Dr.
Reik thinks well of the suggestion. The younger
men would be interested and the older men would
profit. Then the committees on publicity for the
state journals might be avenues for brief articles
dealing with some historic man or event. They
should be short articles which could be read in
about 3 minutes, for longer ones would be passed
over.
I am always interested in what Dr. Ross says.
I think his views are very sound. Conditions have
changed generally and the medical profession must
change and adjust itself to changing conditions.
The day of the gold headed cane and the periwig,
the short trousers and the silver buckles has gone
and they have become a matter of historic rec-
ord. The top hat and frock coat are things that
have passed. It is no longer a time for the medi-
cal profession to continue in a position of aloof-
ness but it must be active and take part in what is
going on. It must make its influence felt in a
practical way. I do not believe much in medical
lobbies in our state capitols, but I do believe tre-
mendously in county activities through proper
committees, discussing problems of medicine with
their representatives, and, after all, the Legisla-
ture is simply made up of units coming from
various communities. The doctors are and should
be influential. Merely to sit down and talk with
them is often quite enough provided they are well
informed, although very often we know they are
not. How many of the rank and file of the pro-
fession are able to talk intelligently and submit
convincing facts to the legislators? Not very
many, I am sure. If we are to start out to edu-
cate the public we must educate ourselves and our
own members and it must be carried on through
their offices and in their communities. We need
leadership, we need study of these problems, and
we need to understand what our relation to these
very important changing industrial and economic
problems is. We would benefit some by studving
trade organizations and their methods, not to adopt
them exactly but to modify them to our own pur-
poses, applying our own ethics and our own ideals.
Of course, one great trouble with the medical pro-
fession is that it is always looking for its defects:
that is our training: we are hypercritical. We talk
about our mistakes more than about our accom-
plishments. We find fault with ourselves and it
is not strange that the laity finds fault with us
and echoes what we say, often adding to it. Our
opponents among the quacks distort these things
frightfully and we suffer the consequence. We are
not given to following leadership. Medicine is the
most individualistic of all professions. We do not
have enough pride in it. Why, the fact of the
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
595
matter is that today the medical graduate is the
best educated product of our civilization, and in
this country our standards of training are uni-
formly higher than those of any other country in
the world. Here and there are nations that com-
pare but do not equal the standards enforced in
this country. And, further, the medical profes-
sion is the best educated profession in this coun-
try today, compared with law, architecture, en-
gineering or the clergy. The doctor comes up to
a higher standard than any of the others. Here
and there are those who equal them but the stand-
ards of medical education are higher than those of
any other profession. A few of the law schools
may equal the medical schools as to their stand-
ards but as a group they fall far short of it.
Dr. Sharpless is somewhat confused by my fig-
ures and I do not wonder. They are not mine
but have been gathered here and there and I
have remembered them because of my interest in
this question of the cost of medical care. They
have been published. Dr. Morgan's Committee
will bring out in systematic and finished form the
facts I have presented. I merely presented them
in an endeavor to give you a more or less con-
crete idea of the subject.
There is one thing that it seems to me is funda-
mental, that medical men are entitled to decide the
extent and the character of their gratuitous con-
tribution to public welfare, but if we are not care-
ful some one else will decide it for us. If we do not
study these problems and maintain our leadership
in the matter, some one else will be directing us.
Dr. Mayer referred to the influence of the
nurses. I am afraid I am quoting figures until I
am becoming tedious but this is a fact and the
figures show it : here in Pennsylvania we have
about 30,000 graduate nurses about half of whom
register annually. If we go back to 1890, there
were 318 nurses graduated from all the training
schools in this country. In 1929 there were 13,000
and in 1950 there will probably be 65,000 at the
present rate of increase.
I would express gratification and appreciation
of your interest and your discussion and reception
of the papers presented.
Dr. Relic extended an invitation to the confer-
ence to hold the next autumnal meeting in Atlan-
tic City, which invitation was duly accepted.
Adjournment at 2.30 p. m.
Communications
CIIIU) GUIDANCE
(Abstract of a pamphlet from William Doody, M.D.,
of Jersey City, Director Traveling Clinic,
Catholic Charities of New York.)
The widespread establishment of child guidance
clinics has been due to an increasing appreciation
of what may be accomplished through applying
the principles of mental hygiene to the study and
treatment of children who present problems of
behavior and personality. Its effectiveness de-
pends largely on an understanding of its functions
and proper adjustment of relationship between the
clinic and the various institutions with which it
cooperates. Therefore, what is a child guidance
clinic? A child guidance clinic is an agency for
study of the child as a whole, in all its reactions,
particularly toward its environment. A clinic con-
sists of a psychiatrist, a psychologist and a psy-
chiatric social worker, each trained in his or her
own field. The chief object of the Traveling Clinic
is to aid the Sisters in adjustment of the particu-
lar children placed under, their care; which means
understanding the child and his reactions.
To carry on successful work there must be co-
operation on every side. The institution and the
clinic must work together to evolve a plan suit-
able for the children in their present environment.
Important in this type of work is an analysis of
the history of the child — not only the history of
his difficulty, but the history of his family through
as many generations as possible, because family
history may have a great influence on problems of
the individual. A knowledge as to mental disease
and chronic physical diseases in the family is im-
portant because a child may be handicapped from
the start because of a poor physical or mental
make-up. Observations by his or her superiors
should be noted; e. g., the attitude in the class-
room, on the recreation field, in competitive games,
in the company of older people, toward playmates
and those in authority. Other important factors
such as shyness, timidity, stubbornness, temper
tantrums, drowsiness in school, insomnia, cruelty
toward younger children and how victory or de-
feat is accepted, should be considered.
Special attention should be paid to the so-called
“shut-in” boy or the one who holds himself aloof
from the group; the boy who is not fond of out-
door sports or male companions, who may be an
apt and model pupil but needs watching because
he .is apt subsequently to develop a mental condi-
tion. A careful physical examination is import-
ant, in which deafness and poor vision may be de-
tected, as such defects may manifest themselves
in abnormalities of conduct. Staff conferences are
valuable because they give an opportunity to all
concerned to discuss the problem and to offer a
means of interpreting and correcting it. Sisters,
teachers and group mothers should feel free to ex-
press their opinions regarding the conduct and
personality of the children, as the psychiatrist is
only an adviser and it is not his aim to disrupt
the institutional plan of child care and training.
It is important to note that spokesmen for such
well known organizations as the Judge Baker
Foundation, in Boston, and the .Institute of Child
Guidance in New York specifically state that in-
vestigation, research and teaching are their major
functions. When the situation is studied more
closely, it is quite evident that much of the treat-
ment in all institutions is left to the teacher and
the group mother, who have been enlightened by
the accurate and painstaking investigation of the
group.
Bach child must be studied as an individual and
his particular abilities and disabilities must be un-
derstood, and he should be educated accordingly.
Many children acquire knowledge easily and repre-
sent the so-called superior child who should be
recognized as such and be given every opportunity
to profit by training in keeping with his mental-
ity. It has been shown that if we place such chil-
dren in an ordinary class where there is insuffi-
cient competition, they become lazy and without
ambition because their intelligence is not being
given sufficient outlet. Such children do better in
a class of superior children. On the other hand,
the normal slow child should be placed in a slow
progress class so that he is not the victim of un-
fair competition with the bright group. The bor-
596
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
derline and definitely defective children do not re-
quire special pedagogic methods but rather a real-
ization that they have subnormal intelligences
and cannot hope to go very far in the regular
grades. Furthermore, it must be realized that
their eventual adjustment in life must be through
the teaching of special work in the nature of man-
ual training, because they will have to earn their
living through manual work. The placement of
these children in vocational classes causes many
behavior problems to disappear because they find
that, at last, they are given tasks which they can
accomplish, and with that comes a satisfaction and
happiness which they have never had previously.
The placement of these children vocationally after
they leave the institution becomes much easier
when they have received vocational training be-
fore discharge, and will, we firmly believe, result
in the elimination of social maladjustments in the
community.
We have found through psychologic examina-
tions that normal children are frequently regarded
as retarded because of the presence of special dis-
abilities; e. g., reading, spelling and arithmetic,
and with correction of these defects through spe-
cial coaching, they are able to assume their proper
places in the school. We have found many be-
havior problems which have depended solely on
the presence of these disabilities.
In conclusion, I would say that the clinic aims
simply to establish a better understanding of the
individual child, who, because of his conduct, does
not seem to be normal, and that the cooperation
of all concerned with his training leads to a better
understanding of him and the installation of rem-
edial measures. The maxim should be cooperation
and team work on the part of all concerned.
ADDITIONAL DISTRICT HEAI/TO
OFFICERS
(A letter from D. C. Bowen, Director of Health,
New Jersey State Health Department, Trenton.)
On and after July 1, 1931, funds will be available
to permit this department to employ four ad-
ditional District Health Officers.
Appointments will be made from a list of can-
didates declared eligible by the State Civil Service
Commission. That Commission has recently fixed
the date of examination of candidates as Thursday,
July 30, 1931. The following information regard-
ing these positions has been published by the Civil
Service Commission.
“District Health Officer — -
Salary, $3000-$4200 per annum. Open to male
citizens, resident of the state for 12 months
immediately preceding the announced date for
this test. Vacancy — State Board of Health.”
DORCAS PRIZE TO NEW JERSEY GIRL
A release from the Gorgas Memorial Institute,
dated June 26, announced that Miss Margaret E.
Beal, a recent graduate from Hammonton High
School, of Hammonton, New Jersey, had won the
Charles R. Walgreen Prize of $100 for writing
the third-best essay submitted by high school
students in the Third Annual Gorgas Memorial
Essay Contest.
The subject of this year’s contest was — “Keep-
ing Fit: the Gorgas Program of Personal Health.”
Miss Beal said: “Although a man is apparently in
good health he should have an annual health ex-
amination and a bi-annual dental examination.
Why? For the very same reason that a man’s au-
tomobile is brought to a garage every 6 months
or so. There isn’t an automobile existing that
doesn't run more smoothly and longer for being
looked over, and every human being is just the
same.”
DEFENSE AGAINST MALPRACTICE SUITS
(An item contributed by Dr. Christopher C. Beling,
Chairman of the State Society’s Special
Committee on Medical Defense.)
At the recent Annual Meeting of the Medical
Society of New Jersey, held at Asbury Park, the
Committee on Medical Defense and Indemnity In-
surance included in its report a recommendation
that 1 column of each issue of the Journal be re-
served for publication of matter pertaining to mal-
practice claims, and to the means of avoiding,
or protecting one’s self against, such suits. It was
the belief of the committee that members of the
society could thus best be kept informed concern-
ing the nature of claims commonly filed, and,
through discussion of actual cases, best advised
how to prevent similar complications.
In such journal space we could report cases, re-
late facts, and discuss pertinent questions, for the
following purposes:
(1) Keeping before members the common or
uncommon errors that occur.
(2) The method to pursue to avoid compromis-
ing statements.
(3) How to treat the unreasonable allegations
of patients.
(4) What is expected of the doctor in such
cases.
(5) What cooperation members may expect
from the Society.
Case reports may serve many purposes and the
Committee urges each member to study these re-
ports so that the number of claims may be dim-
inished, and each doctor may be on guard to avoid,
so far as possible, similar mistakes. A short syn-
opsis of the cases will be made, no names or cities
will be mentioned, and only the essential facts will
be given.
More than 120 cases have been filed in the last
2 years. In 1 case judgment was for a sum of
money nearly double the limit of his coverage.
Naturally, the doctor had to pay the balance;
which amounted to about $10,000.
Adequate protection best preserves your interest,
and by being prepared beforehand you are twice
protected. The best interests of the individual
doctor and of the Society can be preserved only
through the cooperation of all, and it is to that
end we dedicate this column of information.
Case 1. This concerned an abdominal operation'
that was supposedly successful in every way. At
the end of the second week the patient returned
to her home apparently recovered. About 1 month
later the patient called at the doctor’s office again
complaining of pains in the abdomen. It was de-
cided to operate again. They found that in the
previous operation a sponge and an iron ring had
been left in the abdomen. The patient suffered
shock which caused her death within 30 days.
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
597
What system of checking do you require? Do
you personally supervise every article used and is
each accounted for at the end of the operation?
There is practically no defense in such cases, and
the doctor should be extra watchful.
School Health Department
SUGGESTED LIST OF ACTIVITIES FOR
SCHOOL PHYSICIANS
Allen G. Ireland, M.D.,
Director of Physical and Health Education, State
Department of Public Instruction,
Trenton, N. J.
From observation and reports, the following ac-
tivities are apparently typical of the school physi-
cian's program in New Jersey:
(1) The conduct of an annual health examina-
tion of all pupils, as required by state law.
(2) Conduct of a health examination of all pu-
pils referred to the physician as being in need of
further diagnosis.
(3) Special medical examination of all mem-
bers of athletic team squads.
(4) Conduct of periodic inspections of school
. buildings, together with a report of the findings
to the respective principal and the school admin-
istrator.
(5) Recommendation of standards for the sani-
tation of school buildings, including the work of
janitors and helpers in so far as that work re-
lates to pupil health.
(6) Recommendation of standards for meas-
ures governing the control and prevention of com-
municable disease, including specific instructions
to teachers, principals, nurses, and janitors.
(7) Instruction of teachers by means of meet-
ings and conferences on all matters pertaining to
child health concerning which the teacher should
be familiar.
(S) Supervision of the work of the school
nurse except those phases for which the school ad-
ministrative officer is directly responsible.
(9) Instruction of parents on matters pertain-
ing to pupil health by means of meetings, personal
conferences, letters, leaflets and bulletins. The
public press may also be used.
(10) Special examinations of pupils attending
all special classes, and supervision of the health
activities involved in the conduct of such classes.
(11) Cooperating with the physical education
department in designing health programs for in-
dividual cases.
(12) .A health examination of teachers, janitors
and all cafeteria workers.
(13) Supervision of water, milk, and food sup-
plies.
(14) Conferring with the superintendent of
schools and building principal on all school health
problems that may arise.
(15) Assisting in the development of mental
hygiene in the schools and providing teachers with
the necessary information for putting mental hy-
giene into practice in the classrooms.
(lfi) In some places the school physician is
subject to call in emergency cases. There is some
doubt as to the justification of this activity ex-
cept in emergencies of a serious nature. He
should not be called for treatment of minor in-
juries.
’ (17) The school physician should state spe-
cifically what treatments the school nurse may be
permitted to give.
State Health Department
DISTRICT HEALTH OFFICERS
D. C, Bowen, Director
New Jersey State Department of Health,
Trenton. N. J.
These are busy days in the State Department of
Health which is about to witness the consumtna-
tion of a program to strengthen its organization
by the appointment of additional district health
officers. For more than a decade, the department,
with an undermanned staff, has attempted to carry
out the important work of looking after the health
of a rapidly growing state.
Concentrating its efforts to induce the respon-
sible authorities to provide for additional district
health officers, the department about July 1 will
witness the fulfillment of its campaign. Governor
Larson twice included in his budget recommen-
dations provision for the additional health officers.
The Legislature this year voted $12,000 for at least
4 new district health officers. At present there
are but 2. For years, in emergencies, the bureau
of local health administration has dispatched its
trained but limited personnel to municipalities
broadcasting distress signals when communicable
diseases got beyond local control. Health officials
through their various organizations were on record
endorsing the department’s program to so district
the state that the personnel operating from the
bureau of local health administration at the State
House would be so thoroughly organized that un-
usual prevalence of disease could be arrested be-
fore assuming epidemic proportions.
Authority has been given for arrangement of
examinations for civil service for the district
health officers to be named. At present Monmouth
County constitutes one health district. The coun-
ties of Gloucester, Salem, Cumberland and Cam-
den, exclusive of Camden City, constitute the
other health district. Operation of the 2 districts
was cited to the law-makers as a reason for ex-
tending the system to the remaining 16 counties
of the state.
Tentatively the department’s program contem-
plated the grouping of the remainder of the state
as follows:
Cape May, Atlantic, and parts of Ocean and
Burlington counties; Hunterdon, Somerset, Mid-
dlesex and Union; Warren, Sussex and “Morris;
and, Bergen and Passaic. Hudson and Essex, be-
ing practically all urban and having already many
well organized city health departments, might not
need assistance. Mercer and the northern part of
Burlington County could be cared for from the
central office of the department at the State
House.
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
598
Woman’s Auxiliary
PANORAMIC VIEW OF THE WOMAN’S AUX-
ILIARY TO THE AMERICAN MEDICAL
ASSOCIATION IN 4 ARTICLES
No. 3 — Southern District
Mrs. C. W. Garrison
The Southern District of the Woman’s Auxil-
iary to the American Medical Association may
not have moved so rapidly as regards the num-
ber of auxiliaries organized as other sections but
the quality of those existing' have proved them
to be of the greatest value in promoting the aims
of the national body.
Alabama reported 3 counties organized last year,
and is particularly interested in a health pro-
gram giving especial attention to children with a
tuberculous condition. The group visited in Birm-
ingham was alive and interested, and had the co-
operation of its medical society.
Arkansas reported 13 counties organized, all
giving attention to a health program and trying
to raise an adequate loan fund for medical stu-
dents only. Some of the counties contributed ob-
stetric kits for use in the rural districts. Many
of the auxiliary members in Arkansas are devot-
ing much time and energy to the Parent-Teacher
work and are aiding in the various civic and wel-
fare organizations. All will be gratified when the
state is organized 100%.
Florida, large areas of which are sparsely set-
tled, has 10 auxiliaries. Some of these are com-
posed of a combination of 2 or more counties.
Proof of the quality of these groups was seen
when a large medical organization and its auxil-
iary were entertained in Miami, in 1929. Mrs. .T.
Ralston Wells, the little woman who now heads
the State Auxiliary, furnishes further proof of its
aliveness and interest. Florida with its marvelous
fruits, flowers, vegetables and wonderful sunshine
has just as wonderful and marvelous women in
the Medical Society Auxiliary.
Georgia, which has given to the national auxil-
iary one of its most efficient presidents, Mrs. Allen
H. Bunce, has more counties than any other state of
its size and has 21 of these organized. They have
the full approval and cooperation of the State
Medical Association and. having attended that
state convention in 1929, the writer will vouch for
the fact that no national meeting is more replete
with interest and enthusiasm, nor have we found
anywhere a greater desire to foster the aims and
purposes of the national body. No group of wo-
men can possibly have greater courtesy, interest
and encouragement shown them and their work
than is given to the Georgia auxiliary by the medi-
cal men. Mrs. Harrold will bring from her state
a goodly report.
Louisiana reports only 2 parishes organized.
Taking into consideration the fact that one of
these auxiliaries has a greater enrollment than
have some whole states, makes us feel that Louis-
iana will not be far behind in the number of par-
ishes when her final accounting comes in. She is
not lacking in interest in any direction because the
president of the State Auxiliary, Mrs. Harrold, is
of the type who says “We will”.
Mississippi reported 4 auxiliaries last year, and
again we are able to speak with assurance of our
expectations from that state. The president of the
state auxiliary attended the meeting in Detroit and
returned to her state with additional enthusiasm
and determination to gather into the fold more
county organizations. This dream will come true.
Mrs. Polk was the first to respond to our first
circular letter. She has the approval and encour-
agement of the medical men of her state to go
forward.
We may expect to hear of more interest, as well
as more auxiliaries, in North Carolina. Mrs. W. B.
Murphy is the President of this great state auxil-
iary, and though we have before us no report for
last year we do know of its interest in the past
and believe we may hear the number 5 at least
doubled in the next report.
South Carolina shows 13 counties organized, and
Mr,s. Mauldin was prompt to reply with assurances
that better things are ahead for next year.
Mrs. L. M. Sackett now leads the one auxiliary
report from Oklahoma, and we feel certain that
others will be added before June.
On invitation from its President we had the
pleasure of meeting with the Davidson County
Auxiliary in Tennessee early in October, and found
a splendid group of women earnestly desiring to
serve in the most useful way. AVe found as a
member of this auxiliary the State President, Mrs.
Milton S. Lewis. While only 4 auxiliaries are re-
ported from Tennessee, they are the counties in
which the largest cities are located. The dis-
tances are great between, but with the known in-
terest and enthusiasm of the 2 counties visited,
Davidson and Shelby, we are assured that Tennes-
see will bring to the next national meeting a re-
port filled with accomplishments which tend to
fulfill the aims and purposes of the auxiliary.
While we were not fortunate enough to meet
with the Texas auxiliary, we did have a little visit
with the energetic and charming president, Mrs. O.
M. Marchman. Texas, the mother state of the
Medical Society Auxiliary as it is now recognized,
has 35 county auxiliaries, and with a live, inter-
ested organization chairman, such as Mrs. J. T.
Moore is proving herself to be, others will be add-
ed before the next meeting in May. Texas aux-
iliaries have earnestly promoted a health program,
always working shoulder to shoulder with the fine
progressive men of the medical association who,
in turn, endorse the auxiliary movement and are
unstinted in encouragement to further develop-
ment of the organization.
County Society Reports
ATLANTIC COUNTY
Atlantic City Hospital Staff
Joseph H. Marcus. M.D., Secretary
The stated monthly meeting of the General Staff
of the Atlantic City Hospital was held May 15,
with Dr. Milton S. Ireland, President, in the chair.
The medical service of Drs. D. Ward Scanlan and
Harold S. Davidson was reported by Dr. Davidson,
owing to the absence of Dr. Scanlan. The service
embodied the months of November and December
1930 and January 1931. Following a classified por-
trayal of the 191 patients admitted and a discus-
sion of the mortalities, Dr. Davidson continued:
July, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
599
Of especial interest were the pneumonias, of
which there were 14 cases, lobar and bronchial,
not including- tuberculous pneumonias, with 3
deaths, a mortality rate of 21%. This year we
treated our pneumonias with daily, or, in some
cases, twice daily, intravenous injections of con-
centrated glucose solution, to the exclusion of all
other medicaments, and we believe our results
justify continuation of that plan. Until the last
few days of the service it was thought we would
get through without any pneumonia deaths, but
all of a sudden we had the 3 fatalities. This fact
alone shows how impractical it is to draw conclu-
sions from a series of cases as to the value of any
special plan of treatment. It may be that this
year the pneumonias during the early months of
the winter were especially avirulent. At any rate,
we believe the plan should be tried further in or-
der to get some basis for comparison with other
plans of treatment on a larger series of cases.
MERCER COUNTY
A. Dunbar Hutchinson, M.D., Reporter
The Mercer County Society held an “Outing” on
June 18, just a reg'ular out-of-doors picnic in the
grove at the Hopewell Valley Golf Club. The Com-
mittee of Arrangements, Drs. Pierson, Seely, North
and Hutchinson, definitely determined that any
attempt made at scientific discussion on this oc-
cassion would only result in failure because so
many members had availed themselves of the
pleasure and instruction to be gained through at-
tendance upon both the State Medical Society Con-
vention, and the A. M. A. meetings recently held.
Golf and quoits occupied most of the afternoon;
the interval being enjoyed around the buffet lunch
counter tastefully prepared. Many very useful
prizes were awarded to winners in the several con-
tests which were hotly waged in and about the
rough and hubs.
MIDDLESEX COUNTY
Samuel G. Berkow, M.D., Reporter
The June meeting of this society was held at the
Middlesex General Hospital, New Brunswick, on
June 26, at 9 p. m.-, with Dr. William H. McCor-
mick presiding.
Members present were: Drs. Nafey, McKiernan,
Rowland, Johnson, Brown, Feher, Klein, McCor-
mick and Berkow.
Minutes of the previous meeting were read and
accepted.
Dr. McKiernan reported for the committee -on
amending the constitution of the society. Through
the assistance of Dr. Brown he had obtained a
copy of the Constitution of 1884, which is still in
effect. By-Laws of 1816 have been lost. To pro-
vide against such loss in the future, the society
voted, on motion by Dr. Nafey, seconded by Dr.
Rowland, to make the Voorhis Library, of Rut-
gers University, repository of the important docu-
ments of this society.
Dr. McKiernan read the constitution and the
committee’s recommendations. Further changes
were suggested by various members and, on vote,
were incorporated in the committee report. The
revised constitution will be submitted at the
September meeting.
Medical Section of Rutger’s Club
John H. Rowland, M.D., Secretary
The annual , outing of the Medical Section of the
Rutger’s Club was held at 6 p. m., Wednesday,
June 24, at the Ross Fenton Farms, Asbury Park,
with 24 members and 2 guests present.
After various forms of enjoyment in the after-
noon, including the boardwalk promenading, bath-
ing', golf and other recreations, the members en-
joyed an excellent dinner. They also enjoyed the
famous entertainer, Luke Burnett, who acted as
head-waiter, and who was successful in aggravat-
ing 7 or 8 members taken by surprise because un-
aware of this unusual form of entertainment.
Afterward, Mr. Burnett was introduced in his real
personality and told many humorous stories, to the
great satisfaction and pleasure of all those pres-
ent. Besides this form of entertainment, the Ross
Fenton Farms presented music and vocal selec-
tions.
At a late hour the members' adjourned to their
homes, feeling that this was one of the best an-
nual outings they had experienced.
MONMOUTH COUNTY
W. Von Oehsen, M.D., Reporter
The May meeting of the Monmouth County
Medical Society was held at the Garfield-Grant
Hotel, Wednesday evening, May 27, with Dr. W.
K. Campbell in the chair. Minutes and communi-
cations were read and accepted.
Dr. R. W. Baeseman was elected to membership.
The applications of Drs. Davies, Neiderhoffer and
Jordan were read and referred to the Board of
Censors.
Dr. R. A. MacKenzie, chairman of a committee
which met with the committees from the State
Medical Society and the New Jersey State Homeo-
pathic Society to inspect the Dr. E. C. Hazard
Hospital and School of Midwifery, reported as
follows :
“At the conclusion of the inspection and follow-
ing a meeting in which a thorough discussion was
held, it was unanimously voted to sustain the ac-
tion of the State Board of Medical Examiners in
denying approval of Dr. Hazard’s School of Mid-
wifery, such action having been recorded following
inspection of the Hospital and School in April
1930.
No students of midwifery are at present enrolled
at the Hazard Hospital, those taking the course
having discontinued their studies in 1929 following
the action of the State Board in refusing admis-
sion to examination of >3 graduates of this school.
Dr. Hazard had been formally notified, following
inspection and consideration of his Institution in
1925, that his school of midwifery could not be
approved and the action of the State Board in
refusing admission to the above mentioned candi-
dates in 1929 has been sustained by the corjrts.
In the meeting of May 14, 1931, of the joint com-
mittee including your representatives, the ques-
tions brought up for discussion were: (1) The
need of midwives in New Jersey; (2) the character
of equipment and availability of material for ob-
stetric practice and practical teaching at the Dr.
E. C. Hazard Hospital; (3) adequacy and accuracy
of the teaching curriculum proposed for the school
of midwifery at this institution. It was decided
600
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
without dissenting vote: (1) That need for aug-
menting the ranks of midwives in this state and
locality is not great; (2) that the equipment and
facilities at the Dr. E. C. Hazard Hospital are not
worthy of highest approval; and (3) that in-
sufficient evidence was demonstrated as to the
quality and sufficiency of theoretic and practical
teaching along standardized and modern lines to
select this institution for the training and gradu-
ation of midwives.”
Dr. Stanley Nichols recommended that the re-
vised Constitution and By-Laws be adopted by
the County Society. His motion was seconded and
carried.
Dr. J. Wiener, of Asbury Park, gave the paper
of the evening on ‘‘heart failure” which was well
received.
June Meeting
The June meeting of the Monmouth County
Medical Society was held at the Log Cabin Inn,
Pleasure Bay, Wednesday evening, June 24. No
business was transacted except the election to
membership of Drs. Sydney Neiderhoffer, L. E.
Davies and J. B. Gordon.
The members had the pleasure of hearing talks
by Dr. John P. Hagerty, President of the State
Medical Society; Dr. W. H. Herman, of Asbury
Park, and Judge Ward Kremer, of Asbury Park.
A steak dinner and dancing were enjoyed by the
members and their waves.
MORRIS COUNTY
Marcus A. Curry, M.D., Reporter
The quarterly meeting of the Morris County
Medical Society was held the evening of June 18,
in the recreation hall of the employees’ cafeteria
building at the New Jersey State Hospital, Grey-
stone Park.
President Sutphen presided over a gathering of
members and guests numbering about 40 ; among
the guests being President Hagerty of the State
Society.
Routine matters were dispatched, including
reading of the minutes of the March meeting and
2 subsequent special meetings, and the proceedings
of the executive committee. Among items of the
latter record was the resignation of Dr. Emory as
Treasurer, which was accepted with regret.
The applications of Drs. Falvello and Perris,
having been reported upon favorably, were voted
upon and they were unanimously elected to mem-
bership. The application of Dr. Attilo Galasso, of
Morris Plains, was duly referred to the credentials
committee.
A communication was read by the secretary
from Dr. Julia Mutchler thanking members for
their support at the recent primary, at which she
was nominated for Assemblywoman, and bespeak-
ing a continuance of support through the Novem-
ber election.
The Nominating Committee submitted the fol-
lowing recommendation of officers for next year,
to be voted upon at the annual meeting in Sep-
tember: President, Fletcher I. Krauss; Vice-Presi-
dent, Frank N. Pinckney; Treasurer, George J.
Young; Secretary, Albert J. Ward; Reporter, Mar-
cus A. Curry; Historian, Henry W. Kice. For
councilor members of the Executive Committee,
Drs. Sutphen, Frost and McElroy. For members
of the House of Delegates of the State Society
for 3 years, Drs. T'eskey and Teller; alternates,
Drs. Gilbertson and Truax. For member to rep-
resent the society on the Nominating Committee of
the State Society, Dr. Costello.
President Hagerty gave a very interesting talk
on matters of fundamental interest to medical men,
during which he touched upon the subject of con-
trol of specialization and expressed his views, and
the steps that have been taken to give full con-
sideration to the proper handling of this matter
that is now inviting much thought, and stressing
the protection that should be given to those al-
ready holding the rights they have earned and
which have been bestowed upon them.
Dr. Costello, being called upon by President
Sutphen, gave a lucid account of the state medical
society meeting at Asbury Park, and discussed
very clearly many points of present and future
interest. After dwelling upon the value and im-
portance of the Journal and of the work of the
Executive and Field Secretaries, Dr. Costello pre-
sented a resolution which tvas unanimously adopt-
ed, as follows:
“Mindful of the high standard attained by
our State Journal and appreciating the excel-
lence of the work done by our Publication
Committee and our Executive and Field Sec-
retaries, we respectfully request that no meas-
ures be instituted by the Board of Trustees
which will diminish the resources or limit the
activities of those departments.”
Dr. Lath rope gave a very interesting talk along
the lines of specialization and introduced a resolu-
tion which was unanimously adopted:
‘‘That the Morris County Medical Society is
opposed to any legislative regulation in the
realm of specialization.”
The scientific chapter of the evening was pre-
sented by fellow members, Dr. Krauss presenting
5 case reports with x-ray plate illustrations, of
‘‘gastric crises in infants and children”, and Dr.
Costello 2 very “interesting fracture cases”, one
chiefly to show use of the Goldthwait apparatus in
a fracture of the vertebra, the other an “unusual
case of enlarged spleen with abscesses, and ab-
scesses of the liver”.
After adjournment refreshments were enjoyed in
the cafeteria underneath the recreation hall.
SOMERSET COUNTY
Robert Scully, M.D., Acting Reporter
Members of the Somerset Hills Clinical Society,
composed of physicians attached to the new Vet-
erans’ Hospital at Millington, held a joint meeting
with the Somerset County Medical Society at the
hospital on Thursday, June 11. The visiting physi-
cians were accompanied by many of the members
of the Woman’s Auxiliary to the County Medical
Society, and a most interesting program was en-
joyed. All of the visitors were first conducted
through the various departments of the hospital.
The ladies were then entertained at cards and with
music in the beautiful new Recreation Hall which
has been erected on the reservation. Music was
rendered by an orchestra composed of a group of
patients, assisted by Miss Betty Booth, of Basking
Ridge, who sang many delightful songs, and also
July, 3 931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
by Mr. "Boz” Cook, of the Triangle Club of Prince-
ton University, and Mr. Earl Gardner.
Meanwhile, the physicians were given an oppor-
tunity to see medical cases of interest in another
department of the hospital. Dr. Tester W. Day
presented a series of dementia paralytica cases;
Dr. A. C. Delacroix a series of manic cases; and
Dr. D. M- Gardner a most unusual series of neuro-
logic cases.
At 5 p. m. a buffet s/upper was served in the
Recreation Hall, which had been banked with
palms and flowers for the occasion. The hos-
tesses were Mrs. T. F. Neil, Mrs. D. M. Gardner,
Mrs. R. L. Eltinge, Miss Helen Powell and Miss
Mary A. Neill. Assisting were Miss Elizabeth
Brown and Miss Lingenfelder. Tea was poured
by Miss Moxley, Miss Borzner, Miss Berkshire,
Miss Hudson, Miss Brown and Miss Lingenfelder.
Much of the success of the function was due to the
efforts of Miss Mary A. Neill, hospital dietician,
and the whole-hearted cooperation of the workers
of her department.
Obituaries
IN MEMORIAM
JAMES HUNTER, JR., M.D.
SINCE I MUST DIE
(By Scammon Lockwood)
If death must be my lot, my knee I bend
That I die quickly and alone I die;
On no fond breast my parting soul rely,
But sink as traveler at journey's end
And all alone to Erebus descend,
Without one tear, without one parting sigh;
So much for me, but ah, for you, my friend,
1 ask it that the fates may thus defend
Your heart from scourging pain of vigil long;
Slow day and night and week and month and year ;
Ordeal too much for soul or body strong:
Thus I would spare all those who are most dear,
Thus would I join grim Charon’s eager throng,
Quickly to go sans sorrow and sans fear.
6 01
On Monday, June 1, .1.931, Dr. James Hunter, of
Westville, New Jersey, died after a sudden at-
tack of coronary thrombosis, at the age of 65
years.
Dr. Blunter was born in Philadelphia, January
14, I860, the son of James Hunter, Sr., and Martha
M. Church. He was educated in the Philadelphia
public schools and later graduated from the Phila-
delphia College of Pharmacy. He entered the Uni-
versity of Pennsylvania Medical School in 1885,
graduating in 1888 as the youngest member of the
class.
He began his practice in Westville on Decem-
ber 5, 1891, later devoting most of his energies to
the treatment of eye troubles.
Pie was a surgeon on the staffs of the Wills and
Jefferson Hospital eye clinics from 1904 to 1920,
retiring on the death of his chief, Dr. William
Sweet. As a result of his work in those clinics he
established a wide reputation as an eye specialist.
Dr. Hunter was a past-president of both the
New Jersey State Mtedical Society and the Glou-
cester County Medical Society, and at the time of
his death was Secretary of the Board of Trustees
and also a member of the Welfare Committee of
the State Medical Society.
During the World Wjar he served as Chairman of
the Medical Advisory Board for Gloucester County
and was one of the founders of the Physicians’
Association of Woodbury and vicinity. He was a
member of the American Medical Association and
the Medical Club of Philadelphia.
In politics Dr. Hunter was a Republican and
served 3 terms as coroner of Gloucester County.
He is survived by his widow, Elizabeth; a
daughter, Avis, the wife of Carl F. Rumpf, of
Germantown; and a son, James Hunter, 3rd, a jun-
ior in the Woodbury High School.
Resolutions of the Gloucester County Medical
Society on the Death of Dr. James
Hunter, Jr.
RESOLVED, that the Gloucester County Medi-
cal Society records with the utmost sorrow and
regret the sudden death of our esteemed fellow
member, Dr. James Hunter, Jr., of Westville,
New Jersey, on Monday, June 1,- 1931, at the age
of 65 years. Dr. Hunter had suffered from a se-
vere cardiac attack 3 months ago, and had ap-
parently recovered, when suddenly stricken with a
fatal heart attack.
Dr. Hunter was a past-president of the Glouces-
ter County Medical Society, and also of the New
Jersey State Medical Society, and was Secretary
of the Board of Trustees of this latter body at the
time of his death. He also served the State Medi-
cal Society as a member of many important com-
mittees and had for many years been one of the
most influential members of that body. During
the World War, Dr. Hunter served as chairman of
the Medical Advisory Board for Gloucester County.
He was one of the founders of the Physicians’ As-
sociation of Woodbury and at the time of his
death was an active member of the Medical Club
of Philadelphia.
602
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
July, 1931
On January 14, 1X66, Dr. Hunter was born in the
city of Philadelphia. He was educated in the
Philadelphia public schools and the Philadelphia
College of Pharmacy. In 1888 he was graduated
from the University of Pennsylvania Medical Col-
lege and attained high distinction in his class.
Prom 1904 to 1920 Dr. Hunter was a surgeon on
the staffs of the Wills Eye Hospital and the Eye
Clinic of the Jefferson Hospital, of Philadelphia,
where he established an enviable reputation.
Our colleague began the general practice of
medicine in Westville, on December 5, 1891, but
later specialized in diseases of the eye.
By his skilfull and faithful service to a large
clientele throughout Southern New Jersey, and par-
ticularly to the community in which he resided, he
endeared himself to all with whom he came in
contact, for Dr. Hunter emulated in his daily
life and in contact with his patients the lov-
able characteristics of the Great Physician. He
has left a place in the affectionate regard of those
to whom he administered, which will be extremely
difficult to fill.
By his constant and active interest in the Glou-
cester County Medical Society, he had been a
power for good; his association with his fel-
low members had always been kind and consider-
ate. The ethics of the profession always main-
tained a high place in his regard and he was
always a source of inspiration to those of the
profession with whom he came into contact.
BE IT FURTHER RESOLVED, that we, the
members of the Gloucester County Medical So-
ciety, have lost a distinguished, a faithful and a
beloved member; that the state, the county and
the community which he served so long and faith-
fully, has lost a beloved and eminent physician;
and we hereby express our sorrow and profound
sympathy to his family in its bereavement.
BE IT FURTHER RESOLVED, that a copy of
these Resolutions be sent to his loyal and devoted
wife, Mrs. Hunter, and that they be spread at
large upon the Minutes of this Society.
Dated June 4, 1931.
Henry B. Diverty,
William Brewer,
J. Harris Underwood,
Committee.
Resolutions on (lie Death of Dr. James Hunter, Jr.
Adopted by the Board of Trustees of the
Medical Society of New Jersey
The Trustees of the Medical Society of New
Jersey record with deep sorrow and a feeling of ir-
reparable loss the passing of our beloved mem-
ber, Dr. James Hunter, Jr., at his home in West-
ville, Gloucester County, at the midnight hour of
June 1, 1931.
Stricken with an attack of angina pectoris a
few months ago, from the effects of which he had
apparently recovered, he was actively engaged in
preparing to attend our recent meeting at Asbury
Park, and his unfinished report as Secretary of
this Board, on which he was working when the
call came to join Sproul, English, Johnson, Chand-
ler and Dickinson in the Gi'eat Beyond, was fofind
on his desk.
For years his chief professional delight had been
association with these past leaders and with the
present members of this Board. Because of his
integrity, his sterling character and his charm-
ing personality, a deep bond of friendship had
grown up between him and his associates on this
Board.
Dr. Hunter was President of our Society in 1922,
a member of the Board of Trustees for 15 years
and its Secretary since 1925. He loved our So-
ciety as he loved his profession, and scattered
through our “Transactions” in the past are the
records of his devotion. It was during his term as
President that the recent renaissance in the Medi-
cal Society of New Jersey developed, and to him,
in no small degree, was due credit for much of
what has been accomplished.
Members of this Board, of the Fellows, the State
Board of Medical Examiners, the Judicial Council,
Chairmen of Standing Committees, and a host of
physicians from all over the state, attended the
funeral services to pay their last respects to one
who had been a friend to them all.
On behalf of our Society, we express the univer-
sal feeling of grief and loss at the untimely pass-
ing of our friend and counselor.
RESOLVED, That this tribute be spread upon
our minutes and a copy sent to the bereaved
family.
John B. Morrison
Harry R. North
John F. Hagerty.
BLAIR, James A., a practicing physician in
Newark for 30 years, died at his recently acquired
home in Binghamton, N. Y., May 29, 1931.
Dr. Blair was born in Scotland and came to this
country as an infant with his parents. He had
lived in Newark nearly all his life and practiced
many years at his home at 404 Avon Avenue.
Some time ago he retired from active practice and
moved to Binghamton with his wife.
He was a lifelong member of St. Luke,’s Metho-
dist Episcopal Church, a member of the Essex
County Medical Society, the New Jersey State
Medical Society and the American Medical Asso-
ciation.
VOORHEES, Nathaniel Whitaker, formerly of
Elizabeth, died at his home in High Bridge, June 3,
1931.
Born December 4, 1859, the son of the late Na-
thaniel Whitaker and Naomi Leigh Voorhees, he
was a graduate of Rutgers University and the
University of Pennsylvania, from which he re-
ceived his medical degree. After graduation, he
was resident physician at Blockley Hospital, Phila-
delphia, and later practiced medicine in Danville,
Pa., before coming to Elizabeth. In that city. Dr.
Voorhees held an eminent position in his profes-
sion. He was a member of the medical staff of the
General Hospital. A descendant of old American
stock, he was of distinguished appearance. He was
widely read on many subjects, and well informed
on problems of economics and domestic and in-
ternational politics.
About 18 years ago Dr. Voorhees retired from
active practice and with his brother, the late Fos-
ter M. \ oorhees, former Governor of New Jersey,
went to live on his country estate “Hill Acres", at
High Bridge. He resided there until his death.
603
Journal of The Medical Society of New J ersey
Published on
die First Day of Every Month
Vol. XXVIII., No. 8 ORANGE, N. J., AUGUST, 1931
Subscription. $3.00 per Year
Single Copies. 30 Cents
THE CULT OF ASKLEPIOS
Walter B. Stewart, M.D.,
Atlantic City, N. J.
In the early days of Greece, when the gods
of Olympus still roamed the earth, and his-
tory was recorded by word of mouth rather
than on stone or parchment, there lived one
by the name of Asklepios, in later Roman
times called Aesculapius. Little is known of
his life as a man among men. In the time
of Homer, about the tenth century B. C., he
had been dead for 200 years but had not yet
been raised to the level of a god, being known
merely as a famous chieftain of Thessaly who
was well versed in the art of healing and went
abroad doing good and performing miracles.
Homer, in the Iliad, spoke of his sons,
Machaon and Podalirius. who not only were
military surgeons at the siege of Troy but
also commanded a fleet of vessels. Other
authors mentioned his daughters, Hygieia and
Panaceia, who later became assistants in the
temple rites and curators of the sacred snakes.
Asklepios received his medical knowledge, as
did also Achilles, Jason, and other worthies
of the day, from the centaur Cheiron, son of
Saturn, who in turn had been tutored by
Apollo, the Homeric god of medicine and the
' father of Asklepios. Apollo could cause
plagues and epidemics by his arrows, and
could heal the wounds and diseases of the
gods with the root of the peony. On this ac-
count, his name was closely associated with
that of Paean, the physician of the gods, in
the form of Paean Apollo, and to him chorals
or paeans were sung. But it was his son
Asklepios who was the real healer of men.
That he was considered worthy of deification
as god of medicine, was fitting testimonial to
his outstanding ability in the healing art and
to the high esteem in which he was held by his
contemporaries.
We have received a fascinating account of
the birth of Asklepios from the poet Pindar.
Apollo once wooed and won a fair maid,
Coronis, by name, but she, unsatisfied with the
delights of one such love, and despite the fact
that she was with child by Apollo, encouraged
another suitor, a shepherd lad of Thessaly.
The snowy raven, favorite bird of Apollo, es-
pied this scandal and reported it to his mas-
ter. Such was Apollo’s jealous rage that he
turned the snowy raven coal black, seized his
bow, and shot a deadly arrow through the
heart of Coronis, his love. But when he saw
her on the funeral pyre, before the flames
had yet reached her dead body, he relented,
and from her womb snatched the living babe,
Asklepios. Thus was performed the first
Cesarean section, long before the time of
Cesar. One day the infant Asklepios was
found on a hillside by a herdsman, sucking
peacefully at the teats of one of his goats and
guarded by a dog. Ever after the goat and
the dog were considered as animals sacred to
Asklepios.
Another legend told of the discovery of the
secret of restoring the dead to life. One day,
while walking in a garden, Asklepios saw a
snake mourning over the dead body of an-
other snake. Soon the living one began to
crawl about the garden and examine various
plants. It broke off a branch of one herb,
604
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
chewed the leaves, and forced the quid into
the mouth of the dead animal. Immediately
life returned and the recovered snake crawled
away to its nest. Asklepios, marveling at
what he had seen, took careful note of the
herb used.
Asklepios performed so many miracles, and
restored so many of the dead and the dying
to life, that Jupiter, fearful lest he thus de-
prive Hades of all its shades and produce a
race of immortal men on earth, hurled upon
him a lethal thunderbolt. His father, Apollo,
took revenge by killing the Cyclops who had
forged the bolt.
The cult of Asklepios originated in ex-
treme simplicity. A number of devotees of
the new god of healing, enthusiastic patients
who had been cured, and their friends, gath-
ered about a mineral spring on the side of a
beautiful mountain near the little town of
Tricca in Thessaly. There they erected a
simple temple to Asklepios, containing his
statue and a few sacred serpents ; they hung
up their crutches on the walls, just as con-
valescents have always done at famous
shrines ; and they appointed one of their num-
ber to officiate as priest in the worship of the
god. The priest was preeminent ; the phy-
sician had hardly yet appeared in the temple.
The fame of the god and of the shrine, to
which invalids began to flock, spread so rap-
idly throughout Greece that many other tem-
ples were established, the most famous of
which were those at Epidaurus, Cos, Cnidos,
and Pergamos. These temples, or asklepieia,
became popular sanatoriums managed by
trained priests, the asklepiads, and not unlike
many health resorts of modern times. They
were located in elevated spots, preferably on
the side of some mountain, by a medicinal
spring, amidst inspiring natural beauty. The
grounds were laid out with woods, lawns, and
fragrant gardens. Cypress, oak, and olive trees
afforded ample shade. The spring was essen-
tial for purification of the patient and treat-
ment of many of his ailments. About the
temple there were erected beautiful and elab-
orate buildings, often among the noblest and
most imposing examples of Grecian architec-
ture. Ornate in detail, they were adorned
with the most admirable works of the paint-
ers and sculptors of a country so famous,
even then, for cultivation of the fine arts.
The ground plan would resemble in many
respects that of a modern college campus.
Even the stadium, the gymnasium, and the
theatre were there as parts of the course in
occupational therapy. Upon the walls of the
temple were hung the votive tablets, recording
the name of the patient, his disease, and the
manner in which he had been cured. Many
of these tablets have been discovered at Epi-
daurus. Hotels were built for the accom-
modation of the hosts of visitors. Between
200 and 300 asklepieia are known to have
existed in various parts of Greece. Such was
the popularity of the temple cult at these
health resorts that it spread rapidly to the ur-
ban centers. It was introduced into Athens
by Sophocles, in 420 B. C., and into Rome in
an effort to check a raging plague, in 293
B. C.
As the cult grew in influence and complex-
ity, some of the priests assumed more purely
medical functions, although the majority per-
formed only devotional and sacrificial duties.
A few extramural physicians, bringing with
them a knowledge of rational, scientific medi-
cine, were added to the temple staff. It was
assuming more the nature of a great hospital
center. The temple doctors, the asklepiads,
in the century before Hippocrates, were sharp-
ly differentiated from other Greek physicians
by a rigid organization which found expres-
sion in definite rules and formalities. They
were free to practice their calling, at their
own discretion, outside the sacred precincts
or even in foreign countries. At first they
inherited position by primogeniture, but later
were chosen by lot at annual sessions con-
trolled by the state and its politics. Urey
jealously preserved the prerogatives of caste
and exercised their privilege with all that im-
pressive ostentation practiced universally by
the priesthoods of all mystic cults. The as-
klepiads offered not treatment, but cures ; and
the unfortunate incurable was ushered from
the temple as an outcast from divine mercy.
Hence, inasmuch as the cure depended not
upon the sagacity and experience of the heal-
August, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
605
er. but upon the righteousness and purity of
soul of the patient, the asklepian priest was
infallible.
The patient, on admission, was put through
a routine course of treatment. His imagina-
tion having been tuned to the proper pitch
by the inspiring scenery, by the presence of
the god in effigy or in symbol, and by narra-
tion of his famous cures, the patient sacri-
ficed to the god a cock or a ram, and offered
up appropriate prayers. He was further puri-
fied by a bath from the mineral spring, and by
massage, inunctions, and other physico-thera-
peutic measures. He received instructions in
dieting or fasting. Then he was inducted in-
to the special rite of incubation or temple-
sleep, which consisted of lying down to sleep
in the sanctuary for 1 or 2 nights, of dream-
ing, and of having the dream interpreted by
the priest who would then prescribe the ap-
propriate remedy. If the patient was not a
good hand at dreaming, there were profes-
sional mediums who would dream to order for
a small fee. If the patient happened to be
awake during the night, the priest in the
guise of the god presented himself before the
patient to administer medical advice. If the
treatment was successful and he was cured,
the patient presented a thank offering to the
god, usually a model of the diseased part in
wax, silver, or gold ; and he hung up his vo-
tive tablet on the walls of the temple. Thus
the priest was the center of faith of the pa-
tient, effecting his cures by advice and guid-
ance, and depending for his success upon the
credulity of those who sought his aid. Sev-
eral examples of these miracles which have
been preserved for us may be mentioned here :
(1) A skeptic, all of whose fingers save
one were paralyzed, came to the shrine, and
during his period of incubation dreamed of
playing at dice, during which the god straight-
ened his fingers.
(2) Cleo had been with child for 5 years.
After 1 night in the dormitory a son was
born, who in the morn washed himself with
the sacred waters and betook himself from the
shrine.
(3) Pandarus came seeking to have re-
moved some letters branded upon his fore-
head. He dreamed that xA.sklepios bound a
fillet about his head and bade him take it off
and dedicate it to the god. Lo ! In the morn-
ing, the letters were no longer on his troubled
forehead but had been transferred to the fil-
let.
(4) Thyson. the blind boy, had his sight
restored through the licking of his eyes by a
dog of the temple.
(5) A man with an ulcer of the toe was
cured by the forked tongue of the sacred ser-
pent while he lay asleep.
(6) Apellas underwent 9 days of treat-
ment for indigestion. The first item of ad-
vice was not to get angry, following which
there were directions as to diet, exercise, bath-
ing, the making of sacrifices, and the neces-
sity of paying the honorarium. In the event
of his failure to make an adequate monetary
compensation, the disease and suffering of
the patient could be restored to him.
Irrespective of the reality of the cures ef-
fected at these places, one would hardly con-
sider the methods as contributions to medical
therapeutics. The routine of treatment is so
strongly bound up with divine intervention
that it is difficult to distinguish any of the
ancient art of medicine in it. It belongs
rather to the realm of comparative theology.
The popularity of the cult was due in part to
the wisdom and sympathy of the priests, but
mostly to their close association with so
powerful a deity as Apollo.
Parallel with the development and expan-
sion of the cult, scientific rational medicine
was gathering experience and formulating its
rules. Many of its principles originated in
Egypt, Chaldea, and Persia, and were carried
through maritime channels to the lay practi-
tioners of pre-Hippocratic Greece. Hippoc-
rates was indebted to Egypt for much of his
knowledge. His accurate clinical pictures
closely resemble those in the last section of the
Ebers papyrus on the subject of tumors; and
his famous oath corresponds in sentiment and
expression to some of the ethical precepts of
the ancient Egyptian physicians. However,
later Egyptian medicine was entirely in the
hands of the priests, while Greek medicine,
even in the Trojan War, long before the time
€06
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
•of Hippocrates, was largely free from priest-
ly domination. Hippocrates, living between
460 and 376 B. C., developed his great sys-
tem of rational medicine at a time when tem-
ple medicine was exercising its greatest in-
fluence. Greek medicine by no means orig-
inated with Hippocrates ; in reality, he repre-
sents to us the embodiment of a period in
which he forms only the most striking figure.
After he had received what knowledge he
could obtain from the temple of Cos, of which
he was a graduate, he did not disdain to travel
among the secular group of physicians and
learn their art. It is most significant that he,
during the period in which the asklepiads
were most numerous and influential, was
practicing and teaching methods in which the
religious and mystic element was almost neg-
ligible. In his writings he did not mention
the temple at Cos, although his home was at
its very doors and his education was received
within.
Rational medicine and temple medicine
were not necessarily competitive, but perhaps
the asklepaids served as a supplement in at-
tending to those sufferings of humanity which
transcended in their obscurity the wisdom of
rational medicine. The great importance of
the lay practitioner can be realized in the fact
that many Greek cities maintained state phy-
sicians, and that both Homer and Xenophon
told of men of great surgical skill. Even in
the sixth century B. C. Athens boasted of her
public health officers. Democedes, a public
physician of Athens, had an annual salary of
$2000. Although the temples at first repre-
sented depositories of empiric knowledge,
they later became hot-beds of jugglery and
deception. No element of charlatanism en-
tered into the cures of Hippocrates. When
rational means failed, he left the cure to deity
and the “vis medicatrix naturae’’, which force
he recognized as the great physician. Our
word “physician” is derived from the Greek
word “phycis”, meaning nature. The legit-
imate province of his art as a physician he
felt was merely in the aiding of this innate
healing power of nature.
In the fifth century, when the art of think-
ing was being developed to such a high point
among the Greeks, philosophy came to the
aid of medicine and rescued it from the
clutches of religion. The ancient Greek
physicians believed that all disease was of di-
vine origin. They knew about disease only
what could be perceived with their unaided
senses; all else was conjecture and hypothesis.
However, this new philosophic attitude en-
deavored to reduce all thought of phenomena
to a uniformity of idea which led only to guess
work and to neglect of fact. Pythagoras,
Empedocles, and other philosophers, taught
that the macrocosm, or the world as a whole,
was composed of fire, air, earth, and water;
and that the microcosm, or individual unit,
was of blood, mucus, yellow bile, and black
bile. Health was said to consist in a harmony
or due admixture of these humors ; disease,
in a disharmony or imperfect admixture. For
2000 years this humoral pathology dominated
the profession. Even in the Hippocratic
writings the nature of disease was still under
this influence of the philosophers. But, on the
whole, the Hippocratic school freed medicine
of religious and philosophic dogmas and as-
sumptions, and stressed accurate observation
and knowledge from accumulated experience.
Pythagoras, Empedocles, Democritus, Soc-
rates, and other philosophers of that day,
were also distinguished physicians. Few of
their medical writings have been preserved, al-
though we know that Democritus wrote a
treatise entitled : “On Those Who Are Attack-
ed with Cough After Illness”. Plato expressed
some interesting views on the limitations of
temple medicine. He wrote that Asklepios
did not instruct his descendants in vali-
tudinarian arts, because he knew that in well
ordered states individuals with occupations
had no time to be ill. If a carpenter felt sick,
he asked the doctor for a rough and ready
cure — an emetic, a purge, a cautery, or the
knife — these were his remedies. Should anyone
prescribe for him a course of dietetics and tell
him to swathe and swaddle his head, and all
that sort of thing, he could see no good in a
life spent in nursing his disease to the neglect
of his customary employment. Therefore,
bidding goodbye to this sort of physician, he
resumed his ordinary habits and either got
well and lived and carried on his business, or,
August, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
6 07
if his constitution failed, he died and had no
more trouble.
An Athenian father of the fourth century
worried about the poor health and the sus-
picious cough of his adolescent boy, had re-
course to 3 procedures : he could ask the ad-
vice of Hippocrates or some brother prac-
titioner, he could resort to the asklepieion in
Epidaurus, or he could send him to the pal-
estra of Taureas for a systematic course in
gymnastics.
The cult of Asklepios is essentially a re-
ligious sect and unmitigably pagan. It is built
upon the foundation of a mythologic hero or
deity, a legendary figure from among those
earth spirits who were ancient even to Hom-
eric audiences. Such an earth spirit was the
serpent, dwelling in mother earth and hence
symbolic of her. Appearing to be wisei ,
stronger, subtler, and longer lived than man,
it inspired fear and awe, thus awakening re-
ligious impulses. It became a sacred and mys-
tic animal, endowed wdth magic poweis le-
lating to dreams, prophecies, and healing. So,
naturally, it was an almost constant associate
of Asklepios and his cult, and became a sym-
bol of medicine and the medical profession.
The serpent was often worshipped as the god
himself. It was carried to Rome in 293 B. C,
swam ashore, and indicated by the point of its
landing on an island in the Tiber the site on
which should be erected the temple to Asklep-
ios. ' The care of these large, yellow, non-
poisonous, trained serpents was an important
function of the priest and his assistants. It
was believed that the cleansing of one’s ear
by the tongue of a serpent brought about
supernatural understanding in the patient.
Many ulcers and sores were healed by licking
of the forked tongue. The belief in the medi-
cinal qualities of snakes has carried down to
the present day. Do we not find bottles of
rattlesnake oil for the cure of all ailments in
our best drug stores?
You have all seen the statue of Asklepios
standing at the head of the staircase in the
library of the College of Physicians in Phila-
delphia. He is represented as a vmle man
with bared chest, and refined, thoughtful coun-
tenance, garbed in a flowing cloak, and hold-
ing a club-like staff around which coils a
o
single serpent. This staff doubtless had an
Egyptian origin, being derived from the sac-
red uas staff. Hermes or Mercury also car-
ried a staff around which 2 serpents were coil-
ed and surmounted by wings, the so-called
caduceus. Hermes was worshipped by the
early Greeks as a god of healing, the averter
of disease, and as a phallic deity. But the chief
functions of Hermes were as messenger of
the gods, and as the god of merchants, com-
mercial travelers, and thieves. Hence it would
seem hardly appropriate that the medical
corps of the United States army, and many
medical publishers, have adopted the caduceus
of Hermes as the official symbol of medicine
rather than the single-serpent staff of Asklep-
ios. The caduceus was originally the em-
blem of the sun god, Horus, which, mythology
says, Hermes received from Apollo in ex-
change for the lyre. In Assyria it appeared
first at about 3500 B. C. on a libation vase;
and in predynastic Egypt, in a slightly differ-
ent form, on monuments. It was used as a
medical emblem first in the sixteenth century
by a publisher of medical books as a title-page
device.
The sacrificial offering made most fre-
quently to the great god Asklepios was the
cock. In Plato’s description of the death of
Socrates we recall his dying words: “Crito,
we owe a cock to Asklepios”. The meaning of
this solemnly smiling farewell would seem to
be that to Asklepios, a god who always pre-
scribes potions and whose power is manifest
in their effects, was due that most welcome
and sovereign remedy which cured all the pains
and ended all the woes of Socrates, the cup of
hemlock. For this great boon of awakening
into real life Socrates owed Asklepios a thank
offering. This offering of a cock was plainly
intended for him as the awakener of the dead
to life everlasting.
608
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
FACTORS IN THE EARLY DIAGNOSIS
AND TREATMENT OF FRAC-
TURED SKULLS
H. Wesley Jack, M.D.,
Camden, N. J.
In presenting this paper on skull fracture,
it is not the aim or intention of the writer to
bring forth or advocate any new or original
measure or information dealing therewith, nor
has any attempt been made to discuss the
causes of types of skull fractures. It is more
to call to your attention and impress upon
your minds the application of some of the
sound principles of surgery that are beneficial
in conditions associated with the symptoms
resulting from severe trauma to the head as is
so often the case in skull fractures or cranio-
cerebral injuries. As a result of the tremen-
dous growth of automobile traffic, and the
accidents occurring therefrom, it has become
increasingly necessary for the general surgeon
to know more about fractures of the skull.
About 1/5 of the accident cases actually ad-
mitted to the hospital, and many of the cases
admitted to the accident wards, must be con-
sidered and examined for a possible cranio-
cerebral injury. iMore knowledge and ut-
most care must be had in the diagnosis of
these cases, because most of them become
medicolegal cases months later, and the course
one pursues in their treatment is always open
to criticism.
Just what is the duty of the general sur-
geon? In the past 10 years, the tendency in
treatment of cranial trauma has been toward
conservative measures rather than immediate
surgical intervention. The high operative mor-
tality that resulted from rushing all serious
head injuries to the hospital and performing
subtemporal decompression has produced a re-
action in favor of a more careful consideration
of the need for surgery in those cases. The pen-
dulum has swung in the opposite direction
and the general trend of feeling is — do not
open the skull, except as a last resort — while
formerly it was the first procedure; but on
*(Read at the Camden County Medical Society
meeting Jan. 6, 1931.)
the whole, results in mortality have not been
so promising bv the operative method. In the
hands of some, a very low mortality, and in
others, the rate of death high. What has
spelled this difference? Has it been the oper-
ator alone, or is it the class of cases? On the
other hand, in a number of cases in which the
operation was not performed there was a fatal
termination within the first 24 or 48 hours.
Such cases naturally give rise to the question
whether or not surgical intervention might
have changed the course of events.
Hitherto, concussion and continued stupor,
with or without localizing signs pointing to
the area of the brain injured, was considered
by most surgeons as sufficient reason for im-
mediate decompression. As a rule, no at-
tempt was made to estimate the degree or
nature of the injury, or to formulate any rule
upon which to decide for or against opera-
tion. It was considered that in cases of de-
pressed fracture and hemorrhage exploration
should be made, if the general physical con-
dition of the patient justified the procedure.
Numerous classifications of brain injuries
have been given in medical literature but most
of them are only of value from a theoretic
standpoint. To the man doing traumatic surgerv
there are only 2 types of brain injury, those
that should be operated on and those that
should not, or: (1) Those patients who die
no matter what is done, and those recovering
spontaneously without treatment. (2) Inter-
mediate group that usually die if untreated or
that may be saved by timely and intelligent in-
tervention. Our early efforts should be di-
rected to placing patients in one of these
classes, but this cannot always be done. The
injury to the cranial bones is the least im-
portant feature. The prognosis depends in
great measure on the damage that has been
inflicted upon the underlying nervous struc-
tures.
Cushing, in 1908, was the first to call at-
tention to the fact that the injury to the brain
and its membranes, rather than the fracture of
the skull, was the thing to be treated in cranial
injuries. It now seems obvious enough to us
that the primary hemorrhage and compression,
and the secondary swelling and edema, of the
brain and its membranes consequent upon
August, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
609
such injuries cannot be successfully accom-
modated in the closed box which we call the
skull. In addition to this purely mechanical
condition which must be corrected. Weed also
has shown that the fluid balance in the cere-
brospinal system is destroyed by the presence
of blood, which renders absorption impossible.
Our task, then, is three-fold: to restore the
cerebrospinal balance ; to make room for the
reactionary swelling and edema ; and to care,
for the immediate and remote effects of
hemorrhage.
Brain injuries that require operation fall
into 3 classes, and are: (1) Middle meningeal
hemorrhage. (2) Simple or compound frac-
ture with bone pressure or bone fragments in
the brain. (3) Cases in which there is a rapid
increase in intracranial pressure.
Injury accompanied by middle meningeal
hemorrhage should be operated upon imme-
diately after shock reaction. A subdural or ex-
tradural hemorrhage usually offers no diffi-
culty in diagnosis or localization ; due to early
paralysis and pupillary reaction. There is a
monoplegia or paraplegia on the side opposite
the hemorrhage, and in some cases there is
dilation and fixation of the pupil on the side
of the hemorrhage. Retinal examination is of
little diagnostic value at this stage. A subtem-
poral decompression over the area of the
middle branch of the middle meningeal is the
best method of approaching the site of
hemorrhage. Enlargement of the opening can
be easily accomplished to the right or left as
is necessary.
Simple or compound fractures with bone
pressure or bone fragments should be oper-
ated on immediately. Bone pressure should
be entirely removed and a careful search made
for fragments penetrating the brain. Fre-
quently, fragments are overlooked and will
later cause trouble. From the point of view
of intracranial tension, head injuries may be
divided into 2 classes. Immediate operation is
required in patients exhibiting symptoms, to
determine, with fair exactness, the area of the
brain involved. By “immediate operation” is
meant any time after the injury that the pa-
tient has rallied sufficiently to make opera-
tion justifiable. Intracranial tension alone,
without localizing signs, does not require im-
mediate operative opening of the skull, for we
have to contend with pressure caused in large
part by the edema, and we fear overwhelming
medullary pressure and collapse of the vaso-
motor, circulatory and respiratory centers.
Unconsciousness, of itself, has no fatal ten-
dencies ; neither have paralysis, Hutchinson’s
pupil, or an exaggerated reflex. The indica-
tions for treatment should be kept clearly be-
fore you. If you assume that pressure is not
due to massive hemorrhage, to which refer-
ence already has been made, the pressure of a
traumatized brain can be relieved best by 50%
glucose solution given intravenously and by
repeated lumbar punctures. Glucose is a
hypertonic solution that withdraws fluid from
the tissues into the circulation, where often it
is needed to conserve the blood volume.
Usually 50 c.c. twice a day will suffice, but do
not hesitate to double the dose during the first
24 hours if the medullary picture is threaten-
ing; watch your tracing of pulse rate and
pulse pressure, and when these lines cross as
the former decreases and the latter increases,
the situation is critical. As a subsidiary
measure for the relief of pressure, withdraw
cerebrospinal fluid from the lumbar spine, if
need be twice in the 24 hours, but not without
certain precautionary measures. Do not ruth-
lessly drain off every drop of fluid, but with
the aid of your manometer stop before the
pressure reaches normal. This condition may
be handled as effectively by other means,
namely, lumbar puncture, hypertonic solution
by rectum or veins, and ventricular tap. Sub-
temporal decompression for the relief of
pressure is reserved as a last resort and is
rarely performed in the first 8 hours after
injury; only when a spinal reading of 30 or
above is reached will reduction in the amount
of cerebrospinal fluid lower the intracranial
pressure.
Some surgeons prefer merely decompression
and opening of the dura to reestablish cere-
brospinal fluid balance, while others advocate
drainage by rubber tissue for the period of 48
hours or more. For patients with middle men-
ingeal syndrome or extradural hemorrhage,
decompression would seem to be the only
measure offering any prospect of cure.
The nonoperative cases or brain injuries
CIO
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
that should not be operated on, fall into 2
classes: (1) Extensive injury with lacerations
and separations. (2) Injury in which there
is no primary increase in intracranial pressure,
but where pressure usually develops later; due
to fluid accumulation and edema. Included
in this class are the simple, nondepressing
fractures and so-called cases of concussion.
Injuries in which there are extensive lacer-
ations and cellular separations reach a rapid
stage of exhaustion and medullary paralysis.
1 hese massive types of brain injury are fatal
and no treatment is of benefit ; patients pass
rapidly into coma and soon die.
The following items are always worthy of
consideration :
( 1 ) Visit and examine the patient at the
earliest possible moment and carefully note
findings.
(2) The element of shock must be con-
sidered and combatted before operative pro-
cedure of any kind is instituted.
(3) Careful examination, both physical
and neuralgic, should be made and repeat-
ed from time to time. Roentgenograms of the
skull should be taken in every case of sus-
pected fracture. In many instances, especially
in cases of basal fracture, the line will not be
shown. On the other hand, when a linear
fracture of the vault or base is shown, this
fact should not be taken as a deciding factor
for operation. Whenever possible, fracture
of the skull should be demonstrated, just as
fractures of the long bones are demonstrated,
but pulse, temperature, respiration and blood
pressure records should be made frequently.
A good custom has been to have the pulse rate
taken every half hour and the blood pressure
at intervals of from to 2 hr., in severe
cases. From a neurologic standpoint: ex-
amine the pupils to see if they are equal or
unequal, react to light and accommodation ;
note whether the ocular muscles are normal ;
is there nystagmus or inequality of the facial
muscles ; deviation of the tongue ; ability to
whistle or purse the lips; bleeding from the
external auditory canal or postnasal space ;
grip of both hands; reflexes of the arms;
epigastric reflexes ; cremasteric reflexes in
men ; patellar and plantar reflexes ; and Ba-
binski ? It is only by watching closelv the varia-
tion in these phenomena that one can judge
the opportune time for operation.
(4) Ophthalmoscopic examination is re-
quired and often may be advantageously re-
peated. It is not believed that the eve-
ground picture in itself is a reliable earlv
guide to the degree of change in intracranial
pressure; this is especially true in the first
few hours after injury. There have been
cases terminating fatally, in which the eye-
grounds have shown little more than over-
filling of the vessels and hyperemia of the
retina. Even with the patient dying shortly
after the injury, the disk margins have re-
mained essentially clear-cut, and the optic cup
has been well seen. After 48 hours, when the
brain has had time to adjust itself to the con-
ditions of increased pressure, the eye-ground
picture becomes more significant.
(5) The mental state of the patient is re-
garded as a fair index of his condition. This
applies principally to those cases in which the
patient is suffering from edema of the brain.
On occasion, decompression has been resorted
to when the patient was exceedingly irritable
and disoriented, provided lumbar punctures
and dehydration had failed to give relief. Un-
less something can he done fairly early to re-
establish normal processes for these patients,
it has been found that they not infrequently
develop post-traumatic neuroses. The recent
work of Dr. Frazier, of draining off all the
cerebrospinal fluid and injecting oxygen in its
place, followed by x-ray examination, has
brought to light many hitherto unknown brain
lesions resulting from what were considered
slight head injuries, and has explained many
of the so-called cases of neurasthenia. Care-
ful examination should be made by the oto-
rhinologist for bleeding from the external
auditory canal, bleeding into the pharynx by
way of the eustachian tube, and perforation
of the tympanic membrane or hemorrhage
within the middle ear. Nasal or postnasal
bleeding suggests fracture at the base of the
skull.
(6) Examination of the spinal fluid, while
not routine, is made in all cases where there is
a possibility of more than simple concussion.
\\ e believe that the spinal fluid pressure read-
ings are of more value than the ophthalmo-
August, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
611
scopic finding during the first few hours. Dr.
Frazier, of the University of Pennsylvania, has
suggested a rule : whenever the pulse pressure
exceeds the pulse rate per minute, lumbar punc-
ture should be performed. Pressure readings
should be taken at each puncture. Many cases
in which bloody spinal fluid is revealed, es-
pecially when it is under increased pressure,
present signs and symptoms of a meningitis
which disappears after the blood has been ab-
sorbed or drawn ofif by repeated punctures.
While we have had no untoward results from
lumbar puncture, we always watch the pulse
and general condition of the patient while the
fluid is being removed, and invariably stop if
the pulse shows any variation either up or
down.
(7) Subtemporal decompression, when
performed for relief of pressure, is usually
drained, for we cannot conceive of getting
sufficient mechanical relief from decompres-
sion alone to accommodate an edematous
brain. The drainage which usually follows
during the first 48 hr. is of great volume, as
judged by the amount of fluid absorbed by
the dressing. We believe it is the drainage
which is largely responsible for relief. Dr.
Frazier states that there can be secreted as
much as 1000 to 1500 c.c. of cerebrospinal fluid
in 24 hr., and the relief from decompression
alone would not be sufficient in many cases.
(8) It is considered proper to operate in
all cases of suspected local hemorrhage, for
we believe that mechanical removal of the clot
is safer than absorption. Dr. Charles Bagiev,
Jr., of the Johns Flopkins University, Balti-
more. after experimental work performed on
18 adult dogs and 26 puppies from 5 different
litters, and also after studying a number of
children and adults, has summarized his re-
port as follows : Autogenous blood or blood
from an animal mixed with the cerebrospinal
fluid in young and adult dogs produces neuro-
logic disturbances varying from slight differ-
ence in behavior to severe convulsive seizures.
Though some of the animals were severely af-
fected bv small quantities of blood mixed with
cerebrospinal fluid, others have survived more
than a year and are apparently normal.
Following the introduction of blood into the
cerebrospinal fluid, there begins a reaction of
the parts of the meninges which have come in
contact with the blood. The meningeal re-
action tends to subside and may disappear as
the blood disappears from the fluid. After
several weeks, the cellular elements are less
numerous in the meninges, but a large amount
of fibrous tissue is present. Later in the course
of the meningeal reaction, changes in the
structure of the cortex are also observed.
Moderate dilatation of the ventricle not in-
frequently occurs following the introduction
of blood into the cerebrospinal fluid of the
young. The condition may occur in adults,
but with less frequency. For example, in 1
case in which a subdural hemorrhage was al-
lowed to absorb, the patient returned 6 months
later with Jacksonian epilepsy. At subsequent
operation, the cortex zvas yellowish in color,
and many adhesions were present at the site
of the old hemorrhage.
(9) It is now the practice of most men to
open the dura in the majority of cases in which
an extradural clot is encountered. In a case that
it was my privilege to watch, there was found
an extradhral, a subdural and a subcortical clot
in the same general location. After successful
removal of the extradural clot, it was most
discouraging to find that later the patient’s
condition was unimproved ; it was, in fact,
even worse, and upon reopening the wound
and laying back the dura, we discovered a
subdural clot which had not been disclosed at
the first procedure. Opening of the dura may
add slightly to the risk of infection, but a
wide opening is not necessary in order to in-
vestigate the subdural space, and it may be
easily closed.
(10) Local anesthesia is frequently em-
ployed. If the patient is in deep stupor or
coma, the operation may be performed with-
out difficulty. In cases presenting irritability
and restlessness, a combined local and general
anesthesia is employed, a minimum of ether
being used. Large, depressed fractures have
been elevated under local anesthesia when the
patient was conscious throughout the proce-
dure. There is little pain, except when ten-
sion is brought to bear by leverage on the
fragments.
(11) Hypertonic saline (15 to 25%) has
been employed intravenously in a number of
612
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 19 31
cases to reduce intracranial pressure. Most
men have not been favorably impressed with
the results and have come to rely chiefly on
dehydration by the administration of mag-
nesium sulphate, either by mouth or rectum,
as advised by Dr. Frazier. From 1 to lj4 oz.
(28.35 to 42.52 gm.) of magnesium sulphate
are given twice a day when it is possible, or
1 to 3 oz. (28.35 to 85.05 gm.) of crystals
dissolved in 6 oz. (170.1 gm.) of water are
given as retention enemas every 3 or 4 hr., ac-
cording to degree of increased intracranial
pressure. The intravenous use of glucose is
considered by many to be even better than
magnesium sulphate, to dehydrate the brain,
its action more lasting; 20 c.c. of 5% solution
being used. This recalls the teaching of sur-
geons of years past, who prescribed for all skull
fractures a daily dose of castor oil. It appears
that more prompt relief is obtained from re-
peated lumbar puncture than from other
methods.
A good routine treatment of cranial injuries
is as follows :
On admission, the pulse, respiration, tem-
perature and blood pressure are obtained. If
the blood pressure registers below 60 mm. Hg.
in systole, or if the temperature is markedly
subnormal, a state of shock exists. The head
is lowered, external heat applied and 0.5 c.c.
pituitrin given by hypodermic. If external
lacerations are noted, they are cleansed and
explored by incision, often in the accident
ward. Flere, many times, a fracture is shown
to exist and several hours of preliminary ex-
amination is saved. The wound is packed if
there is bleeding, flooded with some antiseptic,
and then covered with sterile gauze. A solu-
tion of 2 to 4 oz. of magnesium sulphate crys-
tals dissolved in 6 oz. of water is allowed to
flow into the rectum. The head-down position
aids in retention of this solution. Lumbar
puncture is performed, with careful man-
ometer readings of the pressure.
Dr. Dandy advises against lumbar puncture,
feeling that it so lowers intracranial pressure
that if extradural or subdural hemorrhage ex-
ists the lumbar puncture, relieving the pres-
sure, allows the hemorrhage to increase. This
is especially true of hemorrhage in the pos-
terior cranial fossa. This same applies to
solutions to dehydrate the brain, and the fact
that blood may be found in the spinal fluid is
not of great consequence, according to Dr.
Dandy. lie advises the following procedure:
(1) Leaving the patient strictly alone, until
you know that nature is unable to cope with
the situation. (2) Study and observe the pa-
tient more carefully. The exact state of in-
tracranial pressure can be determined by : (1 )
State of consciousness. (2) Pulse, respira-
tions, temperature, restlessness, involuntary
micturition or defecation. Fie feels that a
certain percentage, perhaps 20%, will be lost,
with the utmost available efforts, because the
injuries are so severe. About 70% will re-
cover if left alone, and 10% of patients
that would be lost if left alone can be saved
by well timed and well directed operative
treatment.
We are now in a position to determine what
the next step will be. If the neurologic signs
point definitely to one hemisphere, that region
is exposed. This applies only to signs point-
ing to cortical involvement. Paralysis or
definite weakness of one or both extremities
on the same side, convulsions, Jacksonian in
type, motor or sensory aphasia, are the kind of
localizing symptoms required to indicate ne-
cessity for operation. If the neurologic signs
are vague or indefinite, decompression is not
done, unle’ss there is a rapid increase of intra-
cranial pressure and spinal manometer read-
ing of 30 or beyond.
Most patients with cranial trauma are given
the rectal injections of magnesium sulphate.
As a rule, they are insufficient to prevent
manifestations of a rise in intracranial pres-
sure from appearing. If, however, the pulse
and respiration rate continue to be depressed’
or become retarded, and the pulse pressure
continues to rise until it equals the pulse rate,
then other steps are necessary to reduce the
rising tension within the cranium.
Thus, these cases should be subject to very
active and careful study from the earliest
possible moment. Each case is individual ; no
2 seen alike. Only general rules can be used
to govern these and only by the combined or
collective opinions of a team of trained co-
workers can the greatest number be brought
to a successful conclusion. If each patient,
August. 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
613
as soon as possible following the injury, could
be examined carefully and repeatedly by a
corps of trained specialists (surgeon, neuro-
logist. ophthalmologist, otorhinologist, roent-
genologist and laboratory pathologist) the
percentage of correct diagnoses would be
much greater, the course of procedure would
be more definite and certain, and the percent-
age of recoveries would be much greater.
Summary
(1) Intracranial injuries constitute a class
of accidents whose frequency is increasing in
civil life and whose mortality will probably
always be in the neighborhood of 50%.
(2) Attention should be directed to the
damage of cranial contents rather than to
damage of the bony parts, and it should be
remembered that while the immediate re-
covery of the patient is a serious considera-
tion. the remote consequences of the injury
are equally important.
(3) Intracranial hemorrhage should be
drained either by repeated lumbar punctures
or. if that fails, intraventricular puncture, or
by operative means.
(4) The subtemporal decompression de-
vised by Cushing is a valuable measure in
these conditions ; it should never be done dur-
ing the period of shock, and it is wise to sup-
plement it by lumbar puncture or by the use of
dehydrating agents. In mild cases, lumbar
puncture alone may be adequate, but expectant
treatment is seldom justified.
15) A fracture with rapid increase of in-
tracranial pressure demands either dehydra-
tion or operation, next in importance to those
accompanied by hemorrhage. Cerebral edema
is best treated by dehydration, with epsom
salt and glucose, repeated lumbar punctures
and subtemporal or suboccipital decompres-
sion as the occasion may demand.
(6) Skull fractures are not in themselves
fatal. It is. the accompanying complications
that render these conditions so disastrous.
(7) Head injuries, if severe, have a more
favorable prognosis if a linear fracture of the
vault is present to assist in preventing forma-
tion of cerebral edema. We should have more
thorough and repeated examinations by a
corps of trained specialists. We should not
hurry patients to operation ; except those with
active bleeding such as from meningeal in-
volvement. All skull fractures do not require
operation. A simple linear fracture with a
moderate increase in intracranial pressure does
not necessarily indicate operation.
(8) Hematoma of the scalp overlapping
fractures should be evacuated to prevent in-
fection.
(9) The spinal mercurial manometer is a
valuable aid to determine the degree of intra-
cranial pressure.
In conclusion, we desire to state that we do
not advocate spinal puncture as a cure-all, nor
do we want to infer that we prefer the con-
servative method of tapping the spinal canal
instead of the operative method of opening the
skull, but it is firmly believed that its more
extensive use, in selected cases, will prevent
the more serious complication of cerebral
edema, which, if unrelieved, either results in
death or permanent brain damage, with subse-
quent residual symptoms, such as headaches,
mental dulness, change in disposition and
character, and a train of symptoms ascribed
to neurosis.
OCCUPATIONAL DERMATITIS*
John E. Kiley, M.D.,
Newark, N. J.
Injuries of the skin undoubtedly taxed the
skill of the primitive medical man but the first
authentic descriptions of industrial skin dis-
eases were recorded by Italian physicians
early in the sixteenth century. The chimney
sweep’s cancer, grocer’s itch, washerwomen’s
dermatitis, and the dermatoses peculiar to
metal and salt workers, were described. The
scope of occupational diseases has steadily
grown with the development of industries and
new chemical processes, to gain recognition
by dermatologic clinics and organizations in-
terested in industrial hygiene.
Careful and methodic observations of indus-
trial dermatoses were worked out by the
*(Read before the Industrial Disease Institute,
at the Academy of Medicine Building, Newark,
March 3, 1931.)
614
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 19 31
Germans. Ulmann, Oppenheim, and Rille
have made noteworthy contributions in the
classification and description of these affec-
tions. In this country, White of Boston,
made extensive pioneer investigations of ivy
poisoning, of the venenata group. The Ger-
man, French, English and American investiga-
tors have written much on all phases of occu-
pational affections of the skin. Our state has
been ably represented by Dr. Wallhauser, who
was appointed by the Governor to the com-
mission which defined the occupational dis-
eases made compensable in New Jersey.
Varying estimates of their incidence have
been made by clinicians and public health work-
ers ; the consensus of opinion grants that a
high percentage of cases requiring industrial
compensation is limited to trauma and inflam-
mation of the skin. Conservative estimates,
not including domestic workers, attribute
more than 5% of admissions to the dermato-
logic clinics to occupational origin. New in-
dustries have a high incidence and suitable
preventive measures become necessary. The
manufacturers of lubricating compounds, lin-
seed oils, insect powders, and anilin com-
pounds had as high as 30% of employees in-
volved before preventive measures were de-
veloped. Trade specialization creates many
problems, and the sensitized worker finds
difficulty in adapting himself to another trade.
Improved working conditions, suitable cloth-
ing, and personal hygiene have been valuable
preventive measures. Workmen’s compensa-
tion legislation and industrial insurance firms
have encouraged first aid measures to increase
the efficiency of workers. The industrial sur-
geon treats most occupational skin affections,
and only those presenting special problems of
diagnosis, prognosis, and therapy are re-
ferred to the dermatologist, which places the
latter in the role of medical expert and referee.
I erminology for these conditions has un-
dergone evolution from the early descriptions
such as baker s itch and trade eczema. Occu-
pational afiections with the qualifying terms
determining industrial origin, allergic condi-
tion, duration and distribution have found
some usage in the descriptions of the in-
flammatory types. The Germans described 3
classes : the toxicodermias, circumscribed
occupational dermatitis, and occupational
eczema. The toxicodermias are erythematous,
edematous, or exudative inflammations of sud-
den onset and considerable intensity, follow-
ing minor irritations, with a tendency to pro-
gress even after removal of the cause. There
is idiosyncracy to a particular irritant and its
occurrence is comparatively infrequent. The
second group, circumscribed occupational der-
matitis, usually develops in a skin that gives a
normal reaction after prolonged or intensive
exposure to a pronounced irritant, although it
may be due to temporary hypersensitiveness or
increase in strength and activity of the irritant.
Occupational eczema is similar in onset to the
second group and develops in a sensitized skin,
spreads peripherally, and progresses even after
removal of the irritant. This type suggests
skin sensitization and is the more common of
the 3 groups. After careful study there has
been a general recognition that many irritants
produce similar skin reactions, and that a
single irritant may produce a multiformity of
lesions. There are many clinicians in this
country who advocate the term dermatitis in-
dustrial is, qualified to determine the type of
lesion and particular occupation, in order to
give better classification of industrial affec-
tions of the skin.
Knowledge of physiology and biochemistry
is essential to the interpretation of skin dis-
eases. The skin is the largest organ of the
body, usually calls attention to irritation bv
itching, is highly resistant to chemical and
physical agents, affords excellent insulation,
and plays an important part in heat regulation.
The skin is our chief protection against many
diseases and is an important source of anti-
bodies to combat infections which have gained
entrance to the body. It is sensitive to dis-
turbances of metabolism and alteration of
normal body function, and investigation of
skin sensitization and allergy threatens to give
us a new specialty in medical practice.
Inflammatory reactions occur when the
threshold of tolerance is overcome by the in-
tensity or prolonged application of irritants.
Normal tolerance and adaptability protect the
majority from industrial affections. Lowered
threshold tolerance implies hypersensitivity
and may be either local, inherent, or overcome
August, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
615
by adaptation. Disturbances of circulation,
visceral, nervous, and trophic changes, alter
the local reactions. Jaddasohn recognizes a
general susceptibility which renders the skin
sensitive to all forms of irritation, and a
special susceptibility which confines the sensi-
tivity to a single irritant. Predisposing physi-
ologic factors in local tissue reactions are more
noticeable in youthful, senile, blond, and fe-
male skin. Pathologic factors in sensitivitv
are : excessively dry or abnormally moist skin ;
previous injury; debility from disease; and
repeated exposure to irritants. Dyes, soaps,
acids, alkalies., and most inorganic compounds
bring about inflammation and swelling by first
removing or diluting the natural oils in the
upper layer of the skin, then attacking the lin-
ing cells of the follicles and pores. General
predisposing factors are food allergies, ana-
phylaxis, local infection, constitutional dis-
orders, and unhygienic environment. Ichthy-
osis, hvperidrosis, seborrhea, and various cu-
taneous inflammations are predisposing con-
ditions.
The exciting causes are physical, chemical,
occupational, and infectious agents. Under
physical causes are : mechanical traction, pres-
sure, friction, and thermal action which in-
clude the effects of heat and cold ; also actinic
and photo-electric changes produced by
radium, Roentgen, violet, and sun rays. The
chemical causes are : acids, alkalies, oil and
coal tar products ; also many plant and wood
extracts. Many organic, and most inorganic,
compounds produce some irritating effect
upon susceptible individuals. Occupational
exciting causes have been carefully investi-
gated among those employed as mulespinners
in the knitting industry, and workers in shale
oils, pitch, paraffin, tar, asphalt, arsenic, ani-
lin oils and dyes, because of latent keratoses
and cancers.
The infectious agents are : parasitic, my-
cotic, and bacterial organisms. The more
common parasites are those of pediculosis,
scabies, and grain itch. The bacterial and
protozoan organisms are usually secondary in-
vaders, where some mechanical or chemical
agent has broken down the normal integument.
Furunculosis is common among workers in
oils, greases, paraffin, and especially cutting
oils which become mixed with abrasive and in-
fectious material. Erysipeloid is common in
those engaged as commercial fishermen ; also
those who handle meat and cheese products.
Anthrax is encountered in those who handle
imported hides, furs, and bristles. Blastomy-
cosis and actinomycosis are confined mostly
to farmers. Mycotic finger-nail infections
and dermatitis are recognized diseases in fruit
pickers and canners. Syphilis constitutes a
menace to dentists, physicians, and railway
employees.
Pathology. The pathologic changes in the
skin are not specific, and great variation in
effect of the same irritant in different indi-
viduals is recognized. The reaction may be
slowly cumulative, as recognized in x-ray irri-
tation, and tar keratoses and cancers. Irri-
tants in the form of dust or vapor produce
more rapid effects than liquids and solids.
Alteration in strength and composition of
material often precipitates an attack. The
dermatoses are generally localized to the area
of exposure, usually the hands, face, and neck.
In toxic inflammations, the extensor surfaces
of the extremities, face, neck, genitalia, and
areas of opposing skin become involved. Oc-
cupational affections exhibit the primary and
secondary lesions characteristic of nonoccu-
pational diseases, and differentiation is often
difficult. The toxic reactions from mercury,
phenol, arsenic, turpentine, and satinwood are
often scarlitiniform. Etherial and balsamic
oils, such as copaiba, produce measles-like
lesions. Retifonn and pellagra-like eruptions
have been noted in those who handle dinitro-
benzenes and explosive compounds. Acute,
diffuse erythema and purpuric lesions may re-
sult from the absorption of quinin, chromium
salts, benzene, and have been observed in cais-
son disease. Most occupations leave their
trademarks on the skin.
Diagnosis. In attempting a diagnosis, the
localization, character of the skin, and asso-
ciated history must be carefully considered.
The eczematoid and venenata groups give the
most difficulty ; the predisposing factor must
be sought. In cases of dermatitis involving
the hands and face, lie on the alert constantly
for industrial causes. The interpretation re-
quires careful search for local patches of
616
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 19 31
seborrhea irritated by excessive perspiration
and faulty hygiene. If latent seborrheic der-
matitis becomes aggravated by chemicals or
irritants peculiar to the occupation, compen-
sation should be allowed for the limited period
of exacerbation. According to legal interpre-
tation, compensation is not dependent on an
implied assumption of perfect health, and does
not exclude the weak, physically unfortunate,
or those with latent or unknown tendencies to
disease. Mycotic conditions of the hands and
feet, and syphilitic lesions superimposed on
traumatized areas produce perplexing prob-
lems of economic importance. A thorough
knowledge of differential diagnosis is import-
ant ; the responsibility placed on the physician
necessitates the most careful study of all facts
pertaining to the condition, and exhibition of
sound common sense in arriving at conclu-
sions. The physician should not attempt a
medicolegal analysis, nor should he indulge
in hypothetic speculations. Malingering is of
special importance, and self-inflicted lesions
must be suspected in cases of prolonged dura-
tion ; most of these have their origin in bona
fide dermatoses, and healing is prolonged to
gain an increase of compensation.
Prevention and treatment. A patient suffer-
ing from an industrial skin affection, or one
suspected of being such, should be carefully
investigated and reported. Dermatoses are en-
countered in all trades. The clinical data must
be carefully checked, for many occupational
dermatoses are accepted as ordinary skin dis-
eases, since they do not present unusual mani-
festations. Some are of short duration, others
simulate dermatoses of long standing, and
many appear as burns, boils, or other common
skin lesions. Some immediate name is given
to the condition, and the possibility of an
occupational affection is overlooked in the
rush of the clinic, or a sketchy, imcomplete
record is made, especially when the patient
cannot speak English. There should be more
exact analysis of the trade and hygienic en-
vironment. It is not enough to know that a
man is a printer, tanner, or rubber worker;
one must find the irritating agents which he
handles and their effects on the skin. Study
of the processes of vulcanizing, printing, dy-
ing, plating, and other trades have been of in-
estimable value in the proper management of
preventive measures. Tradesmen in the
printing and rubber industries have been care-
fully investigated, and precautionary meas-
ures have greatly reduced the number of cases
of chromium, anilin, and hexamethylenamin
irritation.
Careful hygiene in cleansing the skin, and
care of work clothes have been effective in
those handling stains, dyes, and oil products.
Allergic tests select those who have been sensi-
tized to a particular drug, chemical, or food
product ; oftentimes the individual is sensi-
tized to a group of protein compounds. In a
recent series of cases of occupational derma-
titis, allergic tests in IS gave the etiologic ma-
terial, and the 3 others showed exacerbation
of symptoms on application of the specific
irritant. All cleared up when the specific sub-
stance was avoided. Preventive measures
should be directed by experts familiar with
factory technic, working conditions, material,
and medical administration. Routine medical
inspection should detect those subject to ex-
cessive perspiration, seborrhea and active cu-
taneous diseases, and direct them to suitable
work with advice to use bland protective
measures, and to avoid the use of turpentine,
gasoline, and alkaline soaps as cleansing
agents.
The first treatment is important and as-
sumes correct diagnosis of the lesions. The
strong ointments and antiseptics often used
as first aid measures are important factors in
intensification, extension, and prolongation of
the affection. For acute and nonmalignant
processes, fomentations are in order, followed
later by bland dusting powders or boric acid
ointment. Erythema and Assuring may be
treated with calamine in limewater and olive
oil. Cleanliness and bed rest are important,
and in handling the sequels look for factitial
irritation. Should shagreen skin or licheni-
fication be noted, x-ray treatment will be
valuable. An old employee recovering from
a dermatitis should be placed at other work
sufficiently long to permit the disappearance
of heightened susceptibility to irritation. The
last vestiges of active dermatitis should be
cured before discharge.
August, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
617
A few suggestions for those encountering
irritants are :
(1) Emollients before and after work.
(2) Complete removal of the irritant en-
countered at work by harmless methods sev-
eral times per shift.
(3) Inspection of hands and arms by ex-
perienced observer to enforce: (a) Early
treatment of cuts and burns, (b) Scrupulous
cleanliness of the finger-nails, hands, arms,
and overalls, (c) Removal from irritants, and
prompt treatment of early lesions.
Summary
More accurate classification and recognition
of occupational affections of the skin is
desirable.
Industrial clinics will do much for the iden-
tification, suitable management, and preven-
tion of these affections.
The subject of industrial diseases is being
given increased attention, and the dermatolo-
gist, because of his training, takes an import-
ant part in the development of this field of
medicine.
PREVENTION OF MEASLES IN
PRIVATE PRACTICE*
George Heller, M.D.,
Englewood, N. J.
It has been proved that measles may be
'either prevented or modified by the use of
serum or whole-blood from a convalescent
person, and to a less certain extent by the in-
jection of serum or whole-blood from a per-
son who has at any time had the disease. The
specific prophylaxis is yet unproved. Most
reports concerning measles prevention have
issued from institutions in which facilities ex-
isted for study that do not exist in private
practice. It is for this reason that I wish to
■demonstrate that the prophylaxis (that is, the
prevention or modification) of the disease
may be expeditiously carried out on the out-
side, with no especial difficulty in the use of
*(Read before the Bergen County Medical So-
ciety, Dec. 9, 1930.)
equipment, with no great expense to the physi-
cian or to the patient, and with a minimal
amount of danger.
It may be argued by some that the disease
is of no consequence, and may be disregarded ;
that the disease is bound to be contracted at
some time during life, and may as well be
contracted during the pre-school years as at
any time. To this argument I can oppose a
few telling statistics :
( 1 ) Measles in this country is responsible
for a little less than 1% of all mortality.
(2) Of measles mortality 90% occurs
under the age of 10 (that is to be expected,
because the greater number of cases occur
during those years), but 70% of all measles
deaths occur under the age of 3, although
measles morbidity is higher above the age of 3
that under that age.
(3) There is a mortality under the age of
2, affecting in many epidemics over 10% of
cases.
I doubt that it is generally appreciated that
measles in children under 5 years accounts for
more than 5 times as many deaths as scarlet
fever; almost % as many as diphtheria; and
2/3 as many as pertussis; the 2 latter diseases
being notoriously severe in the very young.
It is also accepted, though I have no figures
to support the premise, that measles is dan-
gerous in children with tuberculosis (active or
incipient) and in those children who have fre-
quent attacks of bronchitis.
The method of prevention that I have em-
ployed uniformly in these cases, is simply the
injection of blood from an adult, who has had
measles, into the muscle of the exposed child.
In the majority of cases I have used the par-
ent, and have therefore contented myself with
assurance regarding recent acute infection and
syphilis ; I have not taken routine Wasser-
mann tests. Compatability of blood is not
essential. I have noted no immediate febrile
response to the injection.
The necessary equipment can be carried in
a small bag : A 20 c.c. Luer syringe and a 20
gauge venapuncture needle, sterile in a sterile
towel ; 1 bottle of iodin ; 1 bottle of alcohol ; a
single swab ; package of sterile gauze squares ;
tourniquet ; and adhesive.
The donor sits or lies adjacent to a chair
618
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
where another individual holds the child prone
on her lap, right hand on the nape of the
child’s neck, and left arm about the bend of
the child’s knees. The donor’s cubital space
produces a turgor of the overlying skin in
small children, but they sit down and run
about with no apparent discomfort in less
than 5 minutes.
and the child’
s buttock are
swabbed
with
In 2 cases
I have seen a
swelling with all
iodin.
Then, about 2
5 c.c. of blood are
with-
the signs of
acute inflammation, together with
drawn
and quickly injected
deeply into the
elevation of
temperature, occurring on the
child's
buttock
The needle
is then
with-
tenth day, but in
each
case
the swelling and
TABLE
No. 1
No.
Name
Age Exposure Temperature Rash Illness
Complication
Remarks
l.
D.B.
3
House
-t-
+ +
0
0
0
2.
R.Z.
10 mo.
House
0
0
0
0
0
3.
A.S.
House
0?
+
-+-
0
0
4.
M.O.
l
House
0
0
0
0
0 (2)
5.
B.S.
2
House
0
0
0
0
0
6.
J.V.
L
House
0
0
0
0
0
7.
C.P.
L
House
0
0
0
0
0
8.
R.H.
2
House
0
+
0
0
0
9.
J.F.
House
0
0
0
0
0 (2)
10.
D.E.
1
House
102
+ + +
+
0
0 others
q-uite ill
11.
J.F.
House
0
0
0
0
0
12.
H.E.
1
House
0
0
0
0 contact
contracted
measles
Number of
cases.
12; prevented, 7 (58%); modified, 5 (42%).
TABLE
No. 2
No.
Name
Age
Exposure Temp.
Rash
Illness
Complication
Remarks
1.
A.W.
5
Play
0
0
0
0
0
2.
M.W.
5
House
103 V2
T + + +
+ + + ■
0
0
3.
M.B.
7?
House
0
0
0
0
Unprotected sibling
also well
4.
E.L.
6
Play
0
0
0
0
r,
M.R.
4%
House
102
++
+ -)-
0
0
6.
A.R.
6
House
102
++
_1_ _L
0
0
7.
M.R.
10
House
103 y2
+-K+
+ + +
0
0
8.
F.R.
6
House
104
+ +Jr+
+ + +
0
Local
reaction.
9.
S.R.
11
House
0
0
0
Measles from 2nd ex-
posure
TABLE No. 3
No.
Name
Age
Exposure
Temp.
Rash
Illness
Compl ication
Remarks
1.
J.P.
10 mo.
? maid
0
0
0
0
0
4- +
2.
M.G.
19 mo.
Visited
0
0
0
0
0
T
Visited
0
0
0
0
0
3.
N.W.
iy2
+ +
Visited
0
0
0
0
Local reaction
4.
D.S.
3
-4—
(Kissed)
5.
D.H.
3
Visited
0
0
0
0
0
+
6.
C.D.
7 mo.
Visited
0
0
0
0
0
drawn and the buttock massaged. The whole
operation consumes less than 1 minute. There
is no necessity for a change of needles, nor
for citration of the blood. The operation is
not essentially painful ; older children who
have in no way been restrained have winced,
but have not cried, and described the injection
as hurting comparatively little. The injection
all symptoms subsided completely in 24 hours.
I have chosen to accept this phenomenon as an
unusual serum reaction rather than the result
of the introduction of microorganisms.
Before presenting the tabulation of results,
it is only fair to explain that the epidemic,
during the course of which this study was
made, was of secondary magnitude, having
August, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
619
about 2/5 the incidence of that in 1926, and
the severity of the cases was minimal. There
was no death reported in Englewood or Tena-
fly, and I and others to whom I have spoken
observed very few complications, none serious.
The total number of children injected was
27 and I have arbitrarily tabulated them in 3
divisions: (1) Very young children with
maximum exposure. (2) Older children. (3)
Very young children, exposure doubtful.
I have attempted to make these tables suffi-
ciently complete to preclude the necessity for
detailed explanation of their content. I have
not noted the day of exposure because in
every case the rash had appeared in the indi-
vidual to whom they were exposed and in no
case did I inject after the fifth day of ex-
posure (accepting the invasion period arbi-
trarily as 3 days.)
On the whole, I am better satisfied with a
case of modified measles than with absolute
prevention. I do, however, feel that post-
ponement of the disease to a later time, when
the infant's fraility has been superseded by
the robustness of the older child, is a worth-
while accomplishment.
I do not feel that the results described in
table number 2 have any positive meaning re-
garding the value of the procedure in older
children, but I feel that table number 1, even
with its relatively small number of cases,
shows a very great preventive value of the
injection. Table number 3 has very little
scientific worth because of the problematic
exchange of virus, but the failure to contract
the disease after known exposure sufficient to
prompt several of the parents to request in-
oculation. is rather unusual unless one accepts
the fact that the blood helped them to escape
infection.
In passing, it should be pointed out that the
parents in every instance were glad to co-
operate with us, after the rationale of the
procedure had been explained, and several
anticipated the suggestion by themselves re-
questing the inoculation.
Conclusion
(1) Measles prophylaxis is a sufficiently
simple and safe procedure to be carried out
in the home.
(2) The use of whole-blood from an adult
who has at any time had the disease is effec-
tive in very young children, no failure either
to modify or to prevent the disease having
been noted in this series of cases.
(3) I feel that the use of whole-blood or
serum from an adult is indicated in cases of
known exposure if the child is under 4 years
of age, or, if older, it has any constitu-
tional weakness, such as bronchitis or tuber-
culosis, provided the procedure can be car-
ried out sufficiently early in the period of in-
cubation.
THROMBOSIS AND EMBOLISM*
Frederic W. Bancroft, M.D.,
New York City
Thrombosis and embolism have become
relatively more important in the surgical
world as the improvement in technic has di-
minished many other types of complication.
The sudden exodus of a patient 5 to 15 days
after operation, often occurring as prepara-
tion is being made to leave the hospital, is a
surgical calamity of inestimable moment.
Strangely enough little has been done to dis-
cover the cause and thereby diminish the in-
cidence of thrombosis and embolism. Various
clinics have made statistical reports, and we
know the incidence is higher in certain ab-
dominal operations than elsewhere.
It is generally accepted that trauma, infec-
tion, slowing of the blood stream and in-
creased dehydration of the blood are factors
in producing thrombosis ; nevertheless, some
patients develop thrombosis with a minimum
number of the above factors, while others with
a maximum number remain unscathed. For
this reason we decided to study, at the Fifth
Avenue Hospital, the blood clotting factors
of all patients admitted to the surgical service.
Studies of the prothrombin, fibrinogen and
antithrombin content, with the resultant de-
termination of the clotting index, will be given
in a later part of this article. We believe,
*(Read at the Bergen County Medical Society
Meeting March 10, 1931.)
620
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
from this study, that we may prognosticate in
the case of the patient who is apt to develop
thrombosis, and we believe that certain thera-
peutic agents may be administered that will
decrease the incidence.
Physiochemical studies reveal that blood
plasma, so long as its constituents are not
dissociated by extraneous forces, is a single
complex in equilibrium, rather than a mix-
ture of substances. The initial views of Har-
vey (1633) and of Woodbridge (1886) have
come again into their own — “blood plasma is
protoplasm and clotting is the last act of liv-
ing blood”.
When blood is shed the plasma dissociates
into substances which yield a clot. During the
latent period of dissociation antithrombin is
precipitated and prothrombin is activated by
calcium ions. The resulting thrombin gels
soluble fibrinogen into insoluble fibrin.
Factors Producing Clotting in the
Blood Stream
Having reviewed the accepted mechanism
of normal clotting, we must now consider
what happens in normal conditions, and why,
in diseases and trauma, we find spontaneous
clotting in the blood stream. The 3 factors
most commonly recognized as producing spon-
taneous blood clotting are: (1) changes in
character of the blood; (2) changes in the
rate of blood flow; and (3) changes in the
vessel walls.
It has long been recognized that a clot can
be started by throwing out to the periphery
the blood platelets when the circulation is
slowed down. As these blood platelets clump
along some portion of the vessel walls there
takes place a coagulation, forming a red clot
around the nucleus of platelets. The great
question which comes up is whether this for-
mation of clot can take place with only a
slowing of the circulation or trauma, or
whether there must be first a change in the
blood-clotting elements of the blood. Some
writers feel that mild damage to the liver
stimulates fibrinogen formation. Others think
it is an interaction of the liver and the ad-
renals. One of the most interesting pieces of
work in this field was done by C. A. Mills
and is concerned with the effect of diet on
clotting and basal metabolism. He showed that
a carbohydrate and fat diet will raise the basal
metabolism but will not increase clotting,
while a protein diet not only raises basal
metabolism but definitely increases the blood-
clotting elements, and attributes this to some
unknown factor connected possibly with the
amino-acids derived from protein meta-
bolism.
In order not to go too far afield, and to
limit the subject so as it may be discussed in
the time allowed, this paper will be limited to
postoperative thrombosis and thrombophle-
bitis, and to embolism which occurs therefrom.
An embolus, as you know, is a blood-clot or
other body carried by the blood-current and
obstructing circulation at point of lodgment.
Obviously, it would be out of place to discuss
tumor, air and foreign body embolism. The
problem of fat embolism, which may be a
considerable factor in postoperative compli-
cations as well as in fractures, is too large
and complex a subject to attempt to discuss
at this time.
Adami describes the difference between
postmortem clotting and thrombosis as fol-
lows: Postmortem dotting. (1) There is no
injury to the vein wall; the clot may be easily
picked out; it is moist. (2) There is no or-
ganization or lamination of the clotting, i.e.,
the blood is coagulated en masse. It may have
2 layers, a pale outer and a dark inner mass.
Thrombosis. (1) The thrombus is attached
to the vein wall, with microscopic evidence of
injury to the intima. (2) It is dry and friable.
(3) There is a definite arrangement of the
contained cells. There are several types of
thrombi : (a) A blood platelet thrombus, white
in gross appearance, and showing, on micro-
scopic examination, a great mass of platelets,
(b) Hyaline thrombus, due to conglutination
of erythrocytes ; on microscopic examination
numerous shadows of erythrocytes may be
seen, (c) Fibrin thrombus is usually small
and microscopic examination shows pure
fibrin in laminated arrangement, (d) White
thrombus is quite common and microscopic
examination shows infiltration with leukocytes,
(e) Red thrombus, which somewhat grossly
resembles a postpartum clot but on micro-
scopic examination shows fibrin and red blood
August, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
621
cells in a laminated arrangement, and it has
more white blood cells and platelets than a
postmortem clot.
Thrombophlebitis is more commonly asso-
ciated with direct injury to the vein wall and
is primarily an infection of the vein with a
secondary thrombosis. On microscopic ex-
amination the entire vein may be infiltrated
with leukocytes and in extreme cases there
may be periphlebitis which may become sup-
purative.
Clinically, one observes 3 main types of
thrombophlebitis: (1) An acute, fulminating
phlebitis, associated with chills, high temper-
ature, redness and tenderness along the course
of the vein, with swelling of the limb. The
thrombus may break down and numerous sup-
purative emboli be distributed throughout the
body. In such cases there is evidence of a
bacteriemia and there may be septic foci in
almost any organ. (2) Acute thrombophlebitis
associated with a moderate elevation of tem-
perature, swelling of the limb, and pain. Fever
may persist for 5 to 15 days. As these cases
are usually observed early and precautions
taken, embolism is not frequent. A clot in the
vessel wall may become organized and the
lumen entirely occluded. Return circulation
of the leg is usually accomplished by either
compensatory dilation of the superficial veins
or a canalization of the thrombus and subse-
quent reestablishment of blood supply through
the affected vein. The present day furore of
obliterating varicose veins makes it impera-
tive to examine every patient coming for in-
jection treatment to rule out the possibility of
a previous thrombophlebitis. If the com-
pensatorily dilated superficial veins are oc-
cluded the leg will again become swollen and
remain so until a second collateral circulation
can be established. Let me cite an incident :
A boy of 19 was operated on, by another sur-
geon, for a loose internal semilunar cartilage
of the knee. His postoperative course was
uneventful, and he left the hospital at the end
of 2 weeks. At the end of 6 months he came
to me complaining of varicose veins in this
extremity. On reviewing his chart I found
that he had run a slightly higher postoperative
temperature than normal. In one of the nurse’s
notes was the statement that he complained of
pain in his leg. The postoperative surgical
notes made no statement about swelling or
pain. There was evidence, when I saw him,
of enlarged anastomotic veins extending from
below Poupart’s ligament upward on to the
abdomen. I advised the patient not to have
■any operation for the enlarged veins. He was
dissatisfied and went to another hospital
where his veins were operated upon. I saw
him 2 months after his discharge from that
hospital, with leg swollen, cold and white, and
he was suffering considerable pain. We must
assume that this patient had a silent thrombo-
phlebitis following his first operation. The
later appearance of varicosities on his legs
was a compensatory act of nature to return
the blood through the superficial veins, as the
deep ones were occluded. At his second
operation the compensatory veins were re-
moved and, as a result, he had a cold, swollen,
edematous leg.
(3) Silent thrombosis. It is probable that
there is very little thrombophlebitis associated
with silent thrombosis. It is this type, run-
ning a relatively normal postoperative tem-
perature, having a sudden massive embolus
occluding large vessels, with resulting death,
that is the most distressing to the surgeon, to
the family and the public at large. It is with
particular reference to this type that we have
attempted, at the Fifth Avenue Hospital, to
study the blood-clotting factors involved.
It would seem advisable at this time to enter
into a philosophic discussion of the causes
of postoperative thrombosis and thrombo-
phlebitis. Analytic reports from surgical
clinics tend to show that these conditions are
more prevalent following -operations upon the
lower abdomen and in fat people, and rarely
do they occur following operations on the
brain and skull. One may ask why this should
fie, for many veins must be traumatized in
skull operations. I venture to suggest the
following factors concerned in their etiology:
(1) Where the surgical approach has been
through the abdominal wall there is constant
motion in the field of repair during the first
48 hours ; in operations on the skull, with the
rigid skull cap, the field is kept at rest. With
every breath taken, and with the usual post-
operative nausea and vomiting, there is a con-
622
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 19 31
stant thrust and pull on the operative field,
which might easily dislodge an embolus or
cause an extension of a small thrombus down-
ward into a larger vein. (2) Approach for an
abdominal operation is through an area of
subcutaneous fat, while in skull operations
there is a relatively small amount of fat. With
the insertion of sutures, often under too great
tension, and with the application of a tight
abdominal dressing, necrosis of the trauma-
tized fat may result. Experimentally, we have
found in dogs that if fat is taken from the
subcutaneous tissues or the omentum and
ground up with a small amount of saline in
a mortar, the resultant fluid contains approxi-
mately 2-4% fat. When this emulsion is in-
jected intravenously a marked rise in the
blood-clotting index is produced. (3) Since
Welch’s classical discussion of thrombosis
and embolism, in Allbutt’s System of Medi-
cine, almost all pathologists and surgeons
have accounted slowing of the blood stream
as one of the primary factors in production
of thrombosis. It has been shown that throm-
bosis rarely occurs in arteries because the cir-
culation of the blood is too rapid. Experi-
ments have been performed, inserting forma-
lin-prepared arterial segments in arterial de-
fects, without subsequent thrombus forma-
tion. Pathologic specimens of aneurysms have
shown that thrombosis occurs in the portion
where there are eddies ; but where a dissect-
ing aneurysm has allowed a rapid flow of
blood, thrombosis 'has not occurred. Following
abdominal operations it has been an almost
universal practice to apply tight surgical
dressings. The distension which usually fol-
lows in 24 hours causes a marked increase in
intraabdominal pressure. If we consider that
the return flow of blood in the vena cava is
largely due to heart suction and respiratory
movements, this increased abdominal pressure
and splinting of the diaphragm must cause
considerable stasis in the veins of the lower
extremities. Moreover, with the almost uni-
versal use of the Gatch bed in the Fowler
position we have the double factors of gravity
and constriction in the region of Poupart’s
ligament, increased by flexion of the thighs
and by the lower border of the tight dress-
ings. (4) Infection or the presence of bac-
teria or their by-products iu the blood stream
is generally advanced as another contributing
factor. These complications may occur where,
to all apparent gross observation, the opera-
tive wound is healed per printum. We know
that bacteria enter the blood stream through
the intestinal walls. With postoperative dis-
tension and slowing down of peristalsis, the
bacterial flora of the intestinal canal must
multiply to a marked degree. Moreover, it
would seem probable that, with the thinning
out of the intestinal wall due to distension,
more bacteria might enter the blood stream.
(5) Dehydration, with resultant increased
viscosity of the blood, is another factor men-
tioned in etiology of thrombosis. It is hard
to estimate in the first 48 hours postoperative
the increase of fluid output over intake. With
preoperative purgation, increased sweating
due to postoperative elevation of temperature,
vomiting and urination, the fluid output is
tremendously increased ; at the same time the
intake of fluids is markedly diminished. If a
patient is vomiting, the oral method of intake
is almost impossible.
Blood-clotting factors. In the beginning of
our study we were impressed with the fact
that some patients with a minimum number of
the known predisposing causes had throm-
bosis occur, while others with a maximum
number escaped. For instance, a woman aged
38 years, after resting her arm on a desk for
4 hours while collecting tickets at a moving
picture theater, developed phlebitis of the
basilic vein of the arm. As a contrast, we
could cite numerous cases of war injury where
there was infection, vascular injury and slow-
ing of the blood stream without resultant
thrombosis. This striking contrast convinced
us there might be something in the blood-clot-
ting factors inherent in an individual that
would be an unknown agent in the production
of thrombosis. We decided, therefore, to
study the clotting factors of each patient ad-
mitted to the stafif service of the Fifth A. venue
Hospital. At the beginning we analyzed the
antithrombin index, the prothrombin index,
fibrinogen, platelet count and the rate of plate-
let dissociation. As the platelet count is
greatly influenced by chronic infection, we
have recently discarded the platelet count and
August. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
623
dissociation rate. As prothrombin and fibrin-
ogen hasten coagulation and antithrombin re-
tards coagulation, a blood-clotting index has
been formed of which prothrombin and
fibrinogen are the numerators and antithrom-
bin the denominator. The detailed descrip-
tion of the tests has been published in an
article bv Bancroft, Stanley-Brown and
Kugelmass, in the Annals of Surgery for
August 1929. It would seem inadvisable to
take up these details at the present time. As
the normal prothrombin is 0.1, fibrinogen 0.5
and antithrombin 0.1. the index then becomes
0.5 ± 0.2.
Blood examinations have been made post-
operatively and, at first, 3 and 5 days later.
Lately, the postoperative examinations have
been changed to 5 and 9 days. The blood of
965 patients has been examined. Not all of
these, however, had preoperative determina-
tions, as some of the patients were refer-
red from the medical clinics and, also, some
examinations hai^e been made elsewhere on
patients suffering from fully developed phle-
bitis. We have considered any patient with
a blood-clotting index of over 0.9 as having a
clotting tendency. In all, we have studied 25
patients who have had clearly demonstrable
thrombosis, thrombophlebitis or embolism,
and with 2 exceptions . these have had high
clotting indices. About 20% of all the pa-
tients examined have had high clotting in-
dices but have not developed an obvious
thrombosis. Nevertheless, almost without ex-
ception these patients have run a rather high
postoperative temperature. For instance, a
hernia patient occasionally would run a tem-
perature ranging from 99° to 100 J for 12 to
14 days without obvious wound infection or
evidence of external phlebitis. Hysterectomies
or gangrenous gall-bladders tend to have high
indices, and we have felt that they probably
had a concealed thrombosis or thrombophle-
bitis and came into the potentially thrombosis
class, but we have not considered them, in our
analysis, as such.
Technic of tests. By venapuncture 9 c.c. of
blood is taken and put into 1 c.c. of 1%
sodium oxalate. The specimen is centrifuged
and the plasma removed. Tests are then made
on the plasma for prothrombin, fibrinogen and
antithrombin. About 40 minutes is required
to do a complete test if the platelet count is
made and platelet disintegration time noted,
but four tests can be done in 1% hours.
We have been able to prove experimentally
on animals and humans that there is only a
slight postoperative rise in the blood-clotting
factors in uncomplicated surgical procedures;
but if a gangrenous process with thrombosis
associated therewith is produced, the clotting
factors rise.
We have had 3 patients with high clotting-
factors, either before operation or shortly af-
terward, who have developed either throm-
bosis or embolism. Allow me to cite 2 illus-
trative cases :
Case 1. A patient admitted for gall-bladder
disease. She had high clotting factors on ad-
mission. Because she had not seemed to us
to be a satisfactory risk, operation was not
considered and the patient left the hospital.
She later returned, on the medical side, with
symptoms suggesting pellagra and was placed
on a high protein diet. A month later she was
admitted to the hospital with a bilateral
femoral phlebitis.
Case 2. A patient was operated upon for
cholelithiasis and benign polyps of the stom-
ach. The operation of cholecystectomy and
gastrotomv for removal of 2 benign polyps in
the pyloric end of the stomach was performed.
On her fifth postoperative day, when tempera-
ture was practically normal and convalescence
apparently satisfactory, she had a high clot-
ting index. On the night of the sixth day
she got out of bed, fell and struck her right
arm. The following morning there was
definite evidence of an embolus in the right
brachial artery. An embolectomy was per-
formed and the blood flow apparently re-
established, but the patient died from shock,
the following evening.
The chemical nature of the clotting com-
ponents has been established, as lipins for the
platelets originating in the bone-marrow, and
globulins for the prothrohibin and fibrinogen
synthesized in liver. Lipins and globulins are
the source of the blood-clotting substances,
initially arising from the daily dietary. This
nutritional basis for the composition of blood
in clotting substances led me to a dietary treat-
624
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 10 31
ment for certain hemorrhagic diseases. In
our animal experiments it had been shown
that an acid diet with high nucleoprotein con-
tent will increase the clotting factors of the
blood, while a basic diet omitting as far as
possible proteins and fats will diminish the
clotting factors. We have also been able to
demonstrate this clinically on human patients.
We feel that this experimental work on the
blood clotting factors is still in a very in-
definite state. The tests for prothrombin, anti-
thrombin and fibrinogen are complex and are
not practicable for routine examinations in a
general hospital. It is our hope that we may
be able to simplify this procedure for adapta-
tion as a routine test even by a relatively un-
skilled technician.
Trfa.tmf.nt
If we base our treatment upon our theoretic
concepts of the etiology of thrombosis and
thrombophlebitis, the following suggestions
can be offered for consideration :
( 1 ) In abdominal cases every effort should
be made to reduce the postoperative nausea
and vomiting in order to keep the field of
operation quiet. In peritonitis, and in high
upper abdominal cases, the Levin tube insert-
ed through the nostril immediately after the
patient has regained consciousness greatly re-
duces vomiting.
(2) The approach for an abdominal oper-
ation is usually through a layer of sub-
cutaneous fat. Experimentally, we have found
that emulsified fat increases markedly the
blood clotting factors. Care should therefore
be taken to avoid traumatizing the fat by over-
zealous pulling of the retractors. Tension
sutures should be loosely tied, because the
secondary edema following operative trauma
rapidly increases tension. Irrigation of the
fat with ether before closure would seem ad-
visable in order to dissolve out the free fat
particles.
(3) Pool, in 1913, published an article on
"Systematic Exercises in Postoperative Treat-
ment”, in which he illustrated the type of ex-
ercises to be used, and recommended that
treatment be started on the third postopera-
tive day. The motion of the arms and legs
would in no way interfere with healing of the
wound, and would tend to improve circulation.
In our opinion, tight abdominal dressings
should be eliminated. G. W. and Kingsley
Roberts, of the Fifth Avenue Hospital staff,
for years have not used any abdominal dress-
ings and have concealed their wounds with
court plaster strips. Their incidence of evis-
ceration or infection has not been greater than
when tight dressings are used. It is our cus-
tom to apply sufficient gauze to cover the in-
cision and to hold it in place with merely
enough adhesive plaster to prevent its mov-
ing. No attempt is made to apply pressure,
and no abdominal binders are used. During
the 3 years this procedure has been followed
there has been only 1 case of wound eviscera-
tion, which was due, I believe, to other causes.
The patients are infinitely more comfortable
and their upper abdominal distension is cer-
tainly less. It has been our custom on the
first day postoperative to inspect all dressings,
and any that feel the least bit tight are loosen-
ed so that the patient is made comfortable.
Even with dressings applied loosely at the
time of operation one is often surprised to
see an expansion of at least an inch after
cutting the adhesive the first day postoper-
ative.
We believe that distension is lessened if
food is given early. Theoretically, it is logi-
cal to assume that if no food is present in the
intestinal tract there is no stimulus for peris-
talsis, and fermentation will take place. If a
bolus of food enters the intestine there is
stimulus for peristalsis, which will carry with
it gas as well as solid material. In uncompli-
cated cases, after spinal, ethylene or gas an-
esthesia, the patient is routinely given tea and
toast the afternoon following the morning
operation.
(4) Fortunately, in most clinics, the giving
of active catharsis the night before operation
is now omitted from preoperative preparation.
Active catharsis, which tends to dehydrate a
patient and make the night before operation
uncomfortable with cramps, is unnecessary.
A mild catharsis given 2 nights before opera-
tion. and an enema the evening and morning
before are sufficient to allow almost any oper-
ative procedure in the abdomen. The routine
August. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
625
administration of fluids, either by intravenous
or subcutaneous methods, will aid toward
diminishing postoperative dehydration. Some
authors have suggested that intravenous ad-
ministration of glucose might be one cause of
increased incidence of thrombosis. Experi-
mentally we have been unable to find any in-
creased clotting factors after glucose admin-
istration.
(5) From our studies of the clinical cases
and of the blood clotting factors, we have
come to believe there are 2 types of throm-
bosis of the lower extremities : (a) The more
or less silent type, with slight elevation of
temperature, but associated with swelling of
the leg and definite venous obstruction, (b)
The septic type, associated with high fever,
frequently bacteriemia, and infection as the
predominant characteristic. Arbitrarily, we
have attempted to treat each type as a separate
entity ; with thrombosis as the predominant
factor, treatment has been by sodium thiosul-
phate.
Although a nonprotein diet is successful in
reducing a high clotting index, it cannot be
depended upon in postoperative cases, for it
is in this group that a quick reaction is often
needed to prevent an accident. We therefore
began to look for some drug which, given in-
travenously, would rapidly reduce the index,
especially in the group in which the prothrom-
bin was high and the antithrombin low.
Sodium citrate was naturally considered, as it
is such a well-known agent for keeping blood
fluid. Our results were good, but large
amounts were required and unless great care
was used in buffering the solutions bad re-
actions were frequent. At the suggestion of
Dr. Lieb, we tried sodium thiosulphate. They
had used this in large doses on animals when
they wanted to prevent clotting in extracor-
poreal tests on the circulation. We found that
it was necessary to give only 10 c.c. of 10%
solution, and repeat the dose in 24 hours, to
obtain the desired effect. Larger amounts can
be given safely but are not needed. We have
used it now on 15 cases, 6 of which had some
form of phlebitis or thrombosis, and 9 re-
ceived prophylactic doses because the index
was found high following operation. In all
but 1 of these cases the index dropped; the
main effect being to lower the prothrombin
and raise the antithrombin. In the case which
did not respond, the prothrombin was normal
and only the fibrinogen high. The chemical
action is not known, but it is probably due to
the sulphate combining with the ionizable cal-
cium and preventing its action with the pro-
thrombin. This, however, is purely theoretic.
The following case illustrates the way it acts
on a postoperative phlebitis : Mary Boylan,
suffering from fracture of the femur, develop-
ed a pulmonary infarction ; following this a
phlebitis of her right leg ; then a second pul-
monary infarction and a recurrence of phle-
bitis in her leg. With the onset of a third
attack of phlebitis, this time in the left leg,
we were called in to see her. At that time her
index was 1.1; prothrombin 1.38; fibrinogen
1.04, and antithrombin 1. We started her on
small doses of sodium thiosulphate. After
daily doses for 4 days her temperature, which
had been running around 101° and 102°, was
down to 99° and 100°, the pain had left the
leg, and her index was 0.84 ; prothrombin
0.93; fibrinogen 0.94; antithrombin 1. As this
had been an extreme case we continued the
sodium thiosulphate every other day for the
next 2 weeks. The index stayed normal and
the patient had no further return of symp-
toms.
In all cases where the solution was used as
a prophylactic measure the index dropped. In
all these cases where the prothrombin was
1.38 it was brought down to 1. The fibrino-
gen was not lowered consistently.
In cases with thrombophlebitis the pre-
dominant factor, following the report of
Shellenberger, in a paper read before the
Southern Surgical Association in 1924, we
have used the intravenous injection of gentian
violet 0.5% solution. The gentian violet crys-
tals are dissolved in sterile, freshly-distilled
water, the solution filtered and injected. The
maximum dose is 5 mgm. per kilo of body
weight. It has been our custom to inject 50
626
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 19 31
c.c. and repeat the dose alternate days for 2
or 3 doses, and we have been impressed by
the satisfactory results obtained. Chills have
occurred in 1 or 2 cases, but of small moment.
Relief from pain has usually occurred follow-
ing the first injection and we have noted in 2
cases a decrease in the circumference of the
leg of 1 to 2 inches in 3 to 4 days. One pa-
tient. who had a severe infection 20 days
postoperative, had an evening temperature of
103' for 4 days before the injection. She
was given 46 c.c. of 0.5% solution. At that
time her thigb measured 24 and her calf 1 1 in.
That night her temperature went to only
100.8 and from there on returned steadily
to normal. The second dose of 50 c.c. was
given 5 days later. In 4 days after the first
injection the thigh had decreased 2Tj in. and
the calf 1 in., and they were of normal consist-
ency and color. Two months after the operation
there was no evident swelling of the leg. We
feel that in the septic type of thrombophlebitis
gentian violet is a therapeutic agent of con-
siderable value. During the 3 years we have
used the above mentioned prophylactic meas-
ures we have not had a sudden death from
embolism. Walters, of the Majo Clinic, has
advised the routine postoperative use of thy-
roid extract to prevent thrombosis and em-
bolism. His results in the series published
are very encouraging: We have not had suffi-
cient experience with this method to form any
opinion of its value.
Conclusions
(1) The application of surgical principles,
such as the avoidance of trauma, the obliter-
ation of dead spaces, and the prevention of
postoperative anemia cf wounds, should re-
duce the incidence of infection.
(2) Experimental work on the blood-clot-
ting factors associated with thrombosis and
thrombophlebitis suggests that there may be
inherent in an individual a predisposing ten-
dency in addition to the generally accepted
factors of infection, slowing of the blood
stream, trauma and dehydration. This work
is in its infancy and is suggested as a possible
prophylactic solution of a surgical calamity.
STATISTICAL STUDY OF DIPHTHE-
RIA IN NEWARK, WITH SPECIAL
REFERENCE TO CASES OC-
CURRING AFTER SCHICK
TEST OR TOXIN-ANTI-
TOXIN IMMUNIZATION
Joseph William Gardam, M.D.,
Director, Communicable Disease Division of
Health Department
Newark, N. J.
Many of my medical friends have asked
from time to time why diphtheria cases in-
creased during 1929 and spring of 1930, and
why diphtheria occurred following Schick-
test and toxin-antitoxin immunization. Be-
cause these questions have arisen so repeatedly
and the interest in the subject seemed so gen-
eral, I felt that I should endeavor to answer
the question to some degree.
If you saw the survey of epidemic diseases
published in the American Medical Associa-
tion Journal, June 1930, you no doubt realize
that Newark holds the unenviable position of
lowest in the list of cities rating 100,000 or
more in population for the year 1929. this rat-
ing being based on disease incidence. Like ev-
erything else, there’s a reason ; Newark’s figure
is a true one and that is more than can be said
for many of the other cities listed. For some
years back the advertising campaign of the
Health Department has stressed the culture
idea. As a result, most doctors culture every
throat showing any congestion, patch or ton-
sillar exudate, no matter how slight. It is
surprising the number of cases that have been
found in this way.
Furthermore, when a case of diphtheria is
reported, the Health Department Inspector
cultures all other members of the family, all
contacts in the quarantined home, and even to
neighboring apartments when such procedure
seems justifiable from the history of ex-
posures obtained from quarantined family.
All contacts in the individual’s class at school
are also cultured by the school authorities.
This results usually in 50 or more cultures
for each case and, as a result, many secondary
cases have been found. This increase in cul-
tural activity has resulted in a great increase
August, 19 31
in our known cases and even though an in-
dividual shows no clinical signs but has had 1
positive culture, it is carried as a case on our
records, whereas in other communities these
are not so classed.
Secondly, the intensive Schick work (by this
I mean testing, immunizing and re-testing)
that has been done, has increased the danger
of infection for those who are not so protect-
ed, because it has broken the chain of direct
contact that ordinarily would give some pro-
tection and at the same time has increased
markedly the number of “carrier cases”. Each
of these carriers, whether temporary or per-
627
manent, has been placed on our books as a
case. The immunization procedure has given
the individual sufficient antitoxin to prevent
his being ill but not enough to prevent carry-
ing live bacilli.
Thirdly, the entire Atlantic seaboard has
passed through an epidemic of no mean pro-
portions with its direct center situated in New-
ark, New York and Philadelphia.
Fourthly, more adequate and zealous at-
tention upon the part of school physicians and
nurses has brought to light another lot of
cases that would usually have been passed by.
(See Chart No. 1.)
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
1930
Population
474,000
Total
1915
Population
375,000
Year Jan.
Feb.
Mar.
CHART 1
DIPHTHERIA
April May June
July
Aug.
Sept.
Oct.
Nov.
Dec.
46
5
7
8
3
6
1
3
1
1
1
6
4
1210
1915
146
138
160
90
83
51
58
51
71
90
112
160
57
7
2
4
6
8
4
6
1
4
3
3
9
923
1916
124
85
70
96
99
71
61
47
29
57
102
76
50
2
5
5
2
7
5
4
1
2
3
7
7
870
1917
79
81
84
70
77
73
44
35
59
103
108
57
82
8
7
7
11
5
4
1
5
11
7
6
10
974
1918
81
112
95
103
63
60
65
49
91
87
77
91
50
5
7
11
7
2
2
2
4
2
0
5
3
1565
1919
154
154
149
161
149
122
96
64
72
121
182
141
62
7
11
5
7
5
1
4
2
1
5
4
10
1022
1920
129
94
95
60
70
72
47
34
44
92
146
139
44
6
5
7
5
3
5
2
2
2
1
3
3
1059
1921
173
128
126
75
102
76
43
24
47
67
78
120
73
13
8
11
7
8
5
1
4
3
2
7
4
771
1922
129
94
73
52
75
36
34
32
43
51
72
80
34
10
3
3
4
2
0
3
0
1
2
4
2
634
1923
89
69
50
40
64
43
24
30
17
57
63
88
39
2
4
6
9
3
1
0
3
0
4
2
5
575
1924
69
64
71
55
50
30
27
33
20
47
42
58
42
6
4
5
4
1
5
2
3
3
3
4
2
509
1925
45
33
53
54
47
39
43
28
27
47
35
58
21
0
1
4
1
4
2
2
1
0
3
1
2
409
1926
45
31
49
24
51
32
23
12
22
32
41
47
62
3
2
7
1
5
0
4
4
4
9
14
9
696
1927
44
47
30
38
34
47
50
30
40
92
121
123
94
7
8
9
10
7
18
6
4
3
1
7
15
1362
1928
107
95
111
94
110
197
83
52
70
113
149
181
92
10
10
9
7
11
5
10
7
5
4
6
8
1717
1929
182
128
184
176
193
132
102
88
78
128
183
143
48
12
8
6
5
6
2
0
3
3
0
0
3
871
1930
116
94
122
147
93
64
39
28
47
40
40
41
Top line figures show deaths.
Lower line figures, number of cases
628
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 10 31
Fifthly, the population of Newark has in-
creased a great deal since 1915 and the type
of population has deteriorated markedly. The
increase in poorly educated, law-defying, su-
perstitious classes is a problem in the control
of all communicable diseases. (See Chart
No. 2.)
Sixthly, cases reported as clinical diphtheria
by a physician are carried on our records as
actual diphtheria, regardless of the fact that
positive cultures are not obtained. In other
words, it is not necessary to have both clinical
and bacteriologic diphtheria for cases to be
definitely classed as such by our Department.
CHART 2
DIPHTHERIA
MONTHS WARDS 1920
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
JANUARY
29
3
9
3
7
6
7
13
12
20
12
10
17
14
13
7
182
FEBRUARY
13
7
10
2
10
6
7
10
4
12
11
6
5
11
4
10
128
MARCH
20
3
13
13
17
8
8
4
11
30
6
9
17
16
3
6
184
APRIL
27
2
7
6
12
4
7
7
6
42
10
9
10
11
11
5
176
MAY
22
8
1
12
15
1
10
11
46
7
13
6
20
10
11
193
JUNE
10
3
8
10
17
1
8
5
27
9
7
7
12
5
3
132
TOTAL
121
18
55
25
68
56
31
52
49
177
55
54
62
84
46
42
995
JULY
5
9
2
3
9
4
8
2
12
8
12
3
10
8
7
102
AUGUST
13
2
9
2
4
5
7
5
3
14
3
6
1
5
4
5
88
SEPTEMBER
7
1
5
2
4
15
1
3
6
7
2
7
3
13
2
78
OCTOBER
17
4
3
7
8
6
1
8
4
12
5
37
8
6
1
1
128
NOVEMBER
22
2
9
2
3
7
2
14
12
28
3
32
11
1 4
14
8
183
DECEMBER
9
9
3
1
3
2
5
7
19
10
47
4
15
2
7
143
TOTAL
1 04
27
99
43
91
101
48
95
83
269
86
195
92
147
77
70
1717
CHART 3
DIPHTHERIA BY AGE SEX COLOR MONTHLY FOR YEAR 1929
Under
Under
5
10
15
20
25
35
45
55
65
Totals
M
F
W
BLK. 1
1
2
3
4
5
9
14
19
24
34
44
54
64
74
Jan.
69
113
174
8
6
12
20
20
25
83
51
15
3
11
13
5
1
182
Feb.
66
62
118
10
4
14
17
11
18
64
21
12
5
4
12
6
2
1
1
128
Mar.
100
84
168
16
3
12
15
27
21
78
62
15
3
7
15
3
1
184
April
86
90
158
18
2
19
18
20
20
79
65
14
2
6
9
1
176
May
95
98
170
23
5
10
24
22
17
78
81
20
4
2
5
3
193
June
63
69
101
31
4
6
11
14
15
50
57
16
2
1
3
2
1
132
July
49
52
88
14
2
8
7
7
7
31
49
8
5
2
2
4
1
102
Aug.
42
46
73
15
2
5
5
7
11
30
41
5
5
2
2
1
2
88
Sept.
41
37
66
12
2
3
5
3
12
25
33
6
2
1
6
4
i
78
Oct.
62
66
110
18
1
6
20
10
11
48
60
9
5
2
3
i
128
Nov.
91
92
161
22
5
7
21
16
10
59
70
27
9
6
7
4
i
183
Dec.
69
74
134
9
4
5
2
17
19
47
49
19
12
4
10
2
143
813
904
1521
196
40
107
165
174
186
672
639
166
57
46
86
38
8
3
2
1717
August, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
629
Our incidence record and Newark's position
in the American Medical Association chart
could be materially improved by requiring all
cases to have both clinical and bacteriologic
signs positive before we classified cases as
diphtheria.
The question of age and its relation to diph-
theria occurrence has been admirably shown in
the accompanying age chart, and this in turn
has been verified by our Schick work. Diph-
theria, as you know, occurs most frequently
under 5 years of age, and that age group runs
90% Schick-positive. From 5 to 10 years is
our second greatest period of diphtheria oc-
currence and runs about 50 to 60% Schick-
74.5 % received antitoxin within 24 hours af-
ter the physician’s first visit.
As to the Schick test and toxin-antitoxin
status in our cases, of the total of 1717 occur-
ring in 1929, we had 67 patients who gave a
history of having been schicked or immunized
some time prior to occurrence of the dis-
ease, and of these, 34 were sent to the Isola-
tion Hospital at Soho at various dates, where
from data at hand we find the following:
One diagnosis changed to acute pharyngitis
with rheumatic endocarditis; 2 negative cases
as to clinical signs ; 1 with patches on right
tonsil, described as noncontagious ; 5 as car-
riers (positive cultures only — no clinical
CHART 4
1928 DIPHTHERIA MORTALITY
95 Deaths: 77
white and 18
colored. No
doctor in attendance
11: hospital
cases
52.
How long was pa-
Same Day
1 Day
2 Days
3 Days
4 Days 5 Days
Uliknown
tient ill before
7
33
24
13
7
4
7
doctor was called?
7.3
34.7
25.2
13. G
7.3
4.2
7.3
When after doc-
Same Day
Next Day
Third Day
Fourth
Day Fifth
Day
Unknown
tor’s 1st visit was
48
23
13
3
3
5
antitoxin given?
50.4
24.1
13. G
3.1
3.1
5.2
W'hen did patient
Within
48 Hrs.
Three Four
Five
Six
Seven
Eight
Nine
Ten Above Ten
die after antitoxin
24 Hr.
I<ater
Days Days
Days
Days
Days
Days
Days
Days
Days
given ?
38
S
6 5
2
3
3
1
3
6
20
39.4
8.4
G.3 5.2
2.1
3.1
3.1
1.1
3.1
6.3
21.0
How much anti-
2000
4000
10,000
20,000
25,000
30,000
50,000
toxin given ?
Lin its
Units
Units
Units
Units
Units
Units
None
18
21
12
13
17
9
1
3
18.9
22.1
12.6
13.6
17. S
9.4
1.1
3.1
Upper Figures: Cases.
Lower Figures: Percentage.
positive. After 10 years of age the case rate
and Schick-positive rates fall rapidly, ordinar-
ily, although the accompanying chart shows
a marked number of cases occurring in the
25 to 35 year period.
Five cases after 55 years of age in 1 year,
is another unusual occurrence. (See Chart No.
3.)
An interesting side light on the diphtheria
situation is shown in an analysis of 95 deaths
occurring in 1928. The chart is self-explana-
tory. (See Chart No. 4.)
It is remarkable that 42% of these deaths
were among patients seen within 24 hours af-
ter onset of symptoms ; and a real compliment
to the ability, judgment and activity of our
physicians is due when one realizes that
signs) ; leaving us 25 cases of actual clinical
diphtheria.
Among private patients not sent to Isola-
tion Hospital at Soho, of which there were 33,
we found : 1 follicular tonsilitis ; 9 positive
cultures with no clinical symptoms; 3 clinical
cases with no positive cultures ; and the bal-
ance of 20 cases definite clinical and bacterio-
logic diphtheria.
Therefore, we have 14 so-called temporary
carriers, 1 pharyngitis, 1 follicular tonsilitis,
2 negatives, and 3 clinical but not bacteriologic
diphtherias, and 45 active clinical and bac-
teriologic cases.
As to the toxin-antitoxin status — all said
they had received 3 doses ; 1 had 4 and 1 had
630
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
CHART 4-A
1928 DIPHTHERIA MORTALITY CHART
95 Deaths — 77 White — 18 Colored
Hospital Cases 52. No M. D. attending 11.
Not Same
Known Day 1 2 3 4 5
WHEN WAS ANTITOXIN GIVEN?
Not Same Next 3rd 4th 5th
Known Day Day Day Day Day
August, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
631
CHART 4-B
24 48 3rd 4th 5th 6th 7th 8th 9th 10th After
hr. hr. Day Day Day Day Day Day Day Day Ten Days
HOW MUCH ANTITOXIN GIVEN?
Thousands
632
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
CHART 5
DOUBTFUL RECORDS
Clinical
Schick and TAT Record
Tonsillar
Laryngeal
Pharyngeal
Cultural Only . .
8 TAT after diphtheria 1 1
1 TAT 12/6/29 diphtheria 12/12/29 1
1 TAT 7/15/29 diphtheria 8/10/29 1
3 Positive Schick 14 months after 3 doses TAT 1
Diphtheria 2 months or less after Schick test 6
TAT doubtful if ever given 9
No proof Schick or TAT given . . 14
CHART 6
DOUBTFUL RECORDS
Date of Date of
Name
Symptoms
Symptoms
T.A.
Re-Schick
Theresa Bauer
5/16
Follicular tonsillitis
1928 (3)
Unknown
Henry Petrueba
8/20
Positive
5/29
Unknown
Joseph Petrueba
8/24
Positive
5/29
Unknown
William Frankmuter
8/10
Cl. tonsillitis
7/15/29
Unknown
Jennie Borkmarki
10/6
Both tonsils
1928
Unknown
M. Nolcome
10/28
9
1928
Neg.
Joseph Plesti
10/5
?
1926
Unknown
Irene Plesti
10/6
?
1927
Unknown
Sophie Solys
10/7
Tonsils
1928
Unknown
G. Studzinski
10/1
Laryngeal Culture
10/1928
Unknown
Stella Polinski
11/11
Culture
3/10/27
5/28 Pos.
Ethel Sykes
11/25
Tonsils
6/1929
Unknown
Lillian Williams
11/30
Pharynx
12/1929
Unknown
Joseph Motuskul
12/12
Tonsil
12/6/29
Unknown
Rosalin Kruger
12/3
Clinic, no culture
11/13/29
No.
Joseph Domarski
12/18
Severe tonsillitis
1929
Unknown
Edward Govenski
12/21
?
1928
Unknown
Evelyn Govenski
12/21
9
1928
Unknown
2 doses, but only 5 were schicked according to
the parent’s statement.
After much investigation on the part of the
Health Department, the trail taking us into
many schools throughout the city, to Soho, to
homes, and to many physicians’ offices, as well
as to Harrison, Perth Amboy, Whippany, Or-
ange, etc., in order to obtain the clinical his-
tory as well as Schick and toxin-antitoxin
status, we managed to get together a decent
record of these cases, numbering 52 in all, and
a questionable record on the balance of 15
cases. This story revealed many facts that
are interesting, and with your permission I
will review the doubtful records first. (See
Chart No. 5.)
Of those histories where an accurate state-
ment was obtained, I shall go into slightly
more detail. We find that 13 children were
re-schicked ; of whom 2 were definitely Schick-
positive and 11 Schick-negative. Out of these
negatives we had 8 temporary carriers. Thir-
teen claimed to have toxin-antitoxin, but no
record was proved in the schools or physicians’
offices.
One case was given toxin-antitoxin after
diphtheria occurred. Diphtheria cases occur-
ring under 3 months after toxin-antitoxin were
14 in number, and in the same month 7. If
you will glance at Chart No. 8 this will be
more clear.
August, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
633
CHART 7
Date of
Name
Symptom
Symptom
3 T. A.
Re-Schick
BA.
12/12
Tonsil
Oct. 1928
No
P.B.
6/15
Tonsil-pharynx
1-6/4/29
No
A.B.
5/26
Tonsil
10/28
Pos. 12/16/29
A.B.
12/21
Mild tonsil
No record
H.C
11/16
Tonsil
Oct. 29
No
C.C.
7/5
No signs, culture
May 29
Neg. 12/11/29
D.C.
12/30
No signs, culture
Nov. 19/29
No
G.C.
10/10
Both tonsils
Absent
No
C.D.
5/16
Neg. 5/2/29
J.D.
5/15
Gangrenous tonsils
May 1928
No
J.E.
11/24
Right tonsil-noncontagious
11/22/29
A.F.
10/5
Culture
Oct. 1928 — No data
M.F.
5/28
Right tonsil
No
No
W.G.
8/3
Both tonsils
6/29
No
S.G.
11/17
SI. tonsil & neg. cult.
6-28
No
W.G.
12/17
Mild tonsil
1927
No
T.H.
11/25
Severe tonsil
3/1929. No school record
No
C.H.
7/17
Naso pharynx
2/1929
No
P.F.
1/19
Not known
No
10/1928 Neg.
E.I.
12/17
SI. both tonsils
Orange, N. J. No record
1. 1.
5/9
Both tonsils
.No
4/18/28 Neg.
E.J.
5/9
Cl. tonsils
Feb. 1929
No
A.L.
8/30
SI. left tonsil
Schick 9/1928 (1)
No
R.L.
6/6
Tonsil
11/1925
Pos. 4/17/28
D.L.
5/12
Both tonsils
1/9/28 (1)
No
P.L.
12/3
Culture
11/22/29
Neg.
A.L.
12/3
Eye and Ear
11/22/29
No record
ILL.
6/8
Tonsil
Dec. 1928
No
A.M.
12/7
Phar.
Cl./ No record
T.M.
11/25
Phar.
4-1926
No
R.M:
5/23
Tonsil pharynx
4/25/28 (1)
No
M.M.
4/15-5/31
Carrier
5/4/29 Neg.
F.M.
10/12
Tonsil
9/26 10/10 (2)
No
R.O.
8/12
Naso-tonsil
4/4/28 Neg.
H.P.
5/20
Culture
Nov. 1927
No
T.P.
5/20
Tonsil
Nov. 1927
No
R.P.
5/21
Culture
Nov. 1927
No
M.P.
5/2
Tonsil
May 1928
No
M.P.
5/16
Tonsil
Oct. 1929
C.P.
3/3
Tonsil
Yes — record doubtful
Perth Amboy
W.R.
5/31
Culture only
Yes
No record
L.R.
5/23
Both tonsils
11/1/28
12/14/28
11/22/28 (2)
Neg.
J.R.
7/9
Acute pharynx, rheum.
& Endocarditis
3/1927
No
J.R.
12/16
Both tonsils
10/1929
No
D.S.
5/20
Carrier
11/1928
No
D.S.
5/10
Both tonsils
Yes 10/28
S.S.
5/31/29
5/15/29
No
R.T.
5/15
Culture
10/26
6-27 Neg.
M.W.
12/3
Mild tonsil
6/28
No
M.S.
12/10
Tonsil
9/1929
No
634
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Aug'ust, 19 31
CHART 8
POSITIVE RECORDS AS TO SCHICK AND
TAT STATUS
Re-schick-positive . 2
Negative 11
Not done 36
Done — not read . . 6
Schick after Diphtheria 2
Schick-negative ... 6
Schick-negative Carriers 8
Incomplete TAT . . 6
Claimed T A T — No record *13
Diphtheria under 3 months 14
Diphtheria same month as T A T given . . 7
•No record but parents certain as to procedure
and dosage.
What conclusions can be drawn from this
mass of figures and charts? That is the im-
portant thing. It is absolutely essential, in
the first place, that a Schick test be done 3 to
6 months after a course of toxin-antitoxin, to
determine if susceptibility still exists. It is a
known fact that Schick work is only 90%
perfect, and that a second series of toxin-
antitoxin is necessary in 10% of our cases.
This 10% is again 90% perfect and we know
that there is a good chance of 1 in 1000 never
attaining immunity.
( 1 ) In the past 7 years I have given some
individuals 3 series of toxin-antitoxin and to
a few individuals 4 complete series, without
any serious reaction or difficulty, and some of
them still show definite positive Schick re-
actions. This i^ery error, resulting as it does,
in an unimmunized child in 10% of our cases,
1 leaves a loop hole for cases to occur in an ap-
parently immunized child. It is surprising the
number of physicians who give toxin-anti-
toxin and state the person is immune, fail to
do a Schick test, or even say it is unneces-
sary. The fault in this instance should not be
placed on toxin-antitoxin, but on the physi-
cian.
(2) Incomplete series of toxin-antitoxin
offers little or no chance of obtaining immun-
ity. In some cases 2 doses will suffice but
these cases are rare.
(3) A certain portion of our cases will de-
velop diphtheria while under treatment and
in the period of 3 or 4 months following tox-
in-antitoxin, before they can possibly attain
immunity. This is because toxin-antitoxin
does not immunize of itself, but stimulates the
body to produce natural antitoxin that is long
lasting.
(4) A definite record of what has been
done, kept over a period of years, is essential.
This record should be maintained in the physi-
cian’s office and also in the school as part of
the physical record.
(5) The question of an active solution for
testing is absolutely essential. Diphtheria
toxin, although a violent and dangerous
poison, readily disintegrates if not kept under
proper conditions, or may be allowed to dis-
integrate because of age. For this reason,
draw your supplies in small quantities, and
often; remember that 4 hours after the toxin
is mixed with saline it is useless.
Because Schick test solutions are easily
broken down, a number of physicians only
test in groups so that a definite number of
positives should occur to verify the activity
of the given solutions ; unless 10% or more
definite positive reactions occur (not pseudo
or combined) one should regard the solution
as inert and retest the entire group, using an
entirely different lot of solution.
(6) As to technic, it is very easy to say a
child is negative, when as a matter of fact he
is still positive, for if our needle goes .too
deep, it is impossible to get a reaction.
For this reason, I advise the use of a J4
in. needle of 27 gauge, which is exceedingly
fine. This needle should puncture the super-
ficial layer of skin with the opening of the
needle upward so that it is visible through
the skin. The resultant wheal should show
enlarged hair follicles and pores, or else the
injection is not correct. This technic was
beautifully demonstrated this past year when
l personally showed 33% positive in an or-
phanage claimed to be 100% negative. Un-
less one is doing Schick work all the time it
is not advisable to try on an isolated indi-
vidual and claim results that can be doubted.
In all my negative cases I now request that a
second test be done in 6 to 12 months to verify
my own technic.
(7) As to carriers — we know that they are
on the increase, because of our toxin-antitoxin
August, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
635
activities. To themselves, they are not dan-
gerous, but to those who are not protected they
are a menace. The axiom resulting here is —
“be schicked and immunized and don’t worry
about the other fellow”.
(S) As to toxoid. It has advantages, for 2
doses at monthly intervals versus 3 at weekly
intervals for toxin-antitoxin works splendidly
in the very young, but with severe reactions
after 3 years of age.
In closing, let me say again that of our 67
cases, 13 were not proved as to their status by
records at schools, physician’s office, etc., and
were discarded as unreliable, and 18 had
doubtful records (about 50%) as to their im-
mune status — by this I mean no active record
existed although the parents insisted they
were treated; 8 were temporary carriers — -
about 16%; and 56, or 83%, either had no
re-schick or incomplete toxin-antitoxin.
Therefore, in 67 cases occurring after
Schick test or toxin-antitoxin, immunization
boils itself down to 11 true cases out of 1717,
or a little matter of 0.6% for the calendar
year 1929, a record for Schick test and toxin-
antitoxin.
An additional report on the 1930 cases will
be published when ready.
CHART 9
DIPHTHERIA MONTHLY MORTALITY CHART
NEWARK, N. J.
ACTUAL DEATHS WITH COMPARATIVE NORMAL
636
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
DEVELOPMENT OF A POSTMORTEM
SERVICE
Asiier Yaguda, M.D.. F.A.C.P.,
Director of Laboratories,
Newark Beth-Israel Hospital,
C Newark, New Jersey
The value of postmortem studies by ana-
tomic, histologic, bacteriologic and chemical
methods needs no elucidation here. It is suffi-
cient to refer to the recent literature indicat-
ing its wide range of benefit to the hospital,
physician, family of the deceased and the
community at large. Christian strikes the
keynote in his statement : “The number of
necropsies obtained on patients dying in the
hospital is perhaps the best single index of
the professional efficiency of the hospital, of
the eagerness of the staff to learn, and of its
teaching abilities.” Hektoen points out the
value of the autopsy in investigation, and in
education of the physician. Improved profes-
sional morals and conscience are claimed by
McKean in those hospitals where autopsies
are the regular sequence to death. According
to the observations of Friedrichs, attendance
at autopsies encourages more precision and
care at the bedside. The value of the autopsy
to the surgeon is shown by Wilson and Hunt,
and to the roentgenologist by Marquis. Cabot,
Wilson, and Karsner conclusively show the
large number of errors in diagnosis which can
be disclosed by postmortems. The importance
of the autopsy in vital statistics is emphasized
by McKean, Wilson, and Karsner.
Part of the active and progressive program
of the American Medical Association, in its
standardization of hospitals, was a study of
what constituted a hospital suitable for intern-
ship, and Christian, in 1926, urged adoption
by the Association of an autopsy requirement,
recommending 25% of autopsies on all hos-
pital deaths as a minimum requirement. The
following year (1927) the Council on Medi-
cal Education and Hospitals of the American
Medical Association adopted the following
resolution: “That beginning January 1, 1928,
‘(Read before the American Society of Clinical
Pathologists, Detroit, June 20, 1930.)
no hospital be approved for internship which
did not perform autopsies on at least 10%
of the hospital deaths.”
The passing of this resolution was, in my
opinion, one of the outstanding accomplish-
ments of the programs aiming toward better
hospitals. Its effect has been an awakened
interest on the part of hospital authorities,
both medical and administrative, in the de-
velopment of an autopsy service. In any
consideration of this question, we must first
analyze the factors involved.
The attitude of the hospital administration
toward the autopsy is extremely important.
Establishment and carrying out of a method
of procedure conducive to results cannot ob-
tain without the active cooperation of the ad-
ministrative powers. Parnell very aptly con-
cludes— “the percentage of postmortems may
be regarded as an index of cooperation be-
tween the administration and the medical
staff”. The provision of suitable facilities in
the form of a modern autopsy room where
interested physicians may observe the autopsy
without suffocating or feeling that they must
put on overalls, and of proper instruments for
doing autopsy, is an example of administra-
tive cooperation. The administration by its
attitude may also hamper or even nullify any
attempt at obtaining autopsies. I know of a
hospital in which, due to administrative an-
tagonism toward autopsies, bodies v/ere
quickly delivered to the funeral directors be-
fore a postmortem could be performed, even
though permission had been obtained from
the relatives.
The pathologist plays a major role in the
development of an autopsy service. His en-
thusiasm for autopsies and his • ability to
demonstrate to the interested physician the
pathologic changes found during the exami-
nation will stimulate the interest of the resi-
dent and attending medical staffs. Proper
utilization of the material, by the establish-
ment of regular pathologic conferences, will
lead to a perpetuation of this interest.
Occasionally an attending physician will at
first object to the attempt of the hospital to
obtain autopsies. The underlying reasons are
a misconception as to the purpose of the
autopsy and fear that the family of the de-
August, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
637
ceased might get the impression that the at-
tending physician was ignorant of the nature
of the patient’s ailment, or perhaps wrong in
his method of treatment. These are easily
overcome by tactful demonstration of the
pathology found so as not to let the physi-
cian get the impression that he is being shown
up, and by assuring him that nothing will be
said to the family that will in any way put
him in an unfavorable light. As part of our
educational program, I have strongly urged
postmortem examinations on physicians or
members of their families who die in the hos-
pital. This produces a decidedly favorable
reaction on the part of the layman, and I have
been able to obtain permission for autopsies
in many instances because of the knowledge
that Dr. So-and-So, or his wife, or son, had
also been subjected to this type of examination.
Perhaps the most important ally of a hos-
pital wishing to do autopsies is the under-
taker or funeral director. Realizing through
sad experience that an antagonistic funeral di-
rector can greatly hamper, and in many in-
stances completely ruin, our chances of ob-
taining permission, we have undertaken to
study this question with the object in view of
enlisting his aid. In several talks to the Asso-
ciation of Funeral Directors of our county, I
squarely placed before the members the fact
that the autopsy was inevitable if the hospi-
tals of the county were to continue to be
recognized as standard scientific institutions,
and appealed to their sense of civic pride in
these institutions. The problem as it applied
to them was considered. They must receive
the body of the deceased in proper condition
for embalming and they must be given con-
sideration as to time. A method was pro-
posed for the postnecropsy preparation of the
body, which was acceptable to them. In brief,
it consists of so ordering the autopsy that the
embalmer receives the body with intact cir-
culation of the head and arms, and free from
leakage. The funeral director’s greatest ad-
vertisement is to present a body in such con-
dition that the callers will be impressed by
its life-like appearance. This cannot be accom-
plished without proper embalming of the face,
and to get this, the circulation must not be
disturbed. I have adopted the method of
closing by sutures the ascending aorta where
it is cut off from the heart, and tying-off the
beginning of the descending thoracic aorta so
as to form a small cup containing the large
vessels of the arms and head. If the brain
has been removed the carotids are tied inside
the skull, and the base of the skull is sealed
with plaster of paris. This procedure en-
ables the embalmer to pick up the brachial
artery and embalm as successfully as though
no autopsy had been performed. The body is
then rendered free from leakage by tying-off
the trachea, the esophagus and the rectum
where they are cut, and by sewing up all open-
ings communicating with the exterior. After
sponging the body dry, a hardening compound
is put into the abdominal and thoracic cavi-
ties. ,
Concerning the saving of time, it is simply
necessary to have the death certificate ready
for the funeral director when he calls, and to
have the body ready for him at the time ar-
ranged. Our funeral directors are instructed
to keep in touch with the hospital so that they
may receive the body immediately upon com-
pletion of the autopsy, and the autopsy is done
as quickly as possible. Personal talks with
funeral directors who call at the hospital, and
consideration for their feelings and time, have
made many of these gentlemen so friendly
disposed toward autopsies and our institution
that they have often obtained permission for
us when all our own argumentative resources
had failed.
It has been my experience that the relatives
of a deceased patient object to autopsies
chiefly because of the method of approach
and a misunderstanding of the purpose of the
autopsy and the manner in which it is done.
I have known interns to bluntly ask the fam-
ily for autopsy permission in the interest of
medical science and humanity. Of course, a
refusal was the result. In dealing with a
bereaved lamily, we must bear in mind that
nothing must be said to hurt their acutely
awakened sensibilities. The field must first
be prepared for the necropsy request by sow-
ing in their minds a logical and personal
reason for the request. To this end, we dis-
■G3S
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
cuss with the family the possibilities of the
■cause of death from the clinical findings,
being always careful to leave a question of
doubt as to the actual underlying causes of
the fatal termination. Then we discuss the
family ; how many brothers, sisters or chil-
dren does the deceased leave? How did the
father, mother and grandparents die ? Is there
any history of similar conditions in these
deaths? In cases of infection or blood con-
ditions, how close contact was there between
the deceased and his relatives? The solution
is then offered. The hospital is no longer a
place solely for the treatment of disease ; it
has now assumed the role of a preventor of dis-
ease. The hospital offers its resources and
services to the family. It proposes to conduct
a postmortem examination, and asks the fam-
ily’s cooperation and permission. This exam-
ination, understand, is done chiefly for the
benefit of the family. John Doe does not di-
rectly benefit and is not personally interested
in what conditions the deceased is passing on
to his family, either by heredity or contact,
but the family does benefit and should be in-
terested. The family is requested to return
to the hospital in a period of about 2 weeks
to discuss with the attending physician or the
pathologist the results of the examination, and
to receive advice as to any tests or examina-
tions they may recommend. The recital of
cases in point, where the health and welfare
■of entire families were involved, may he of
value in bringing home the idea of heredity
and contact as potent factors in disease.
Should the question of the technic of the
procedure be brought up by the relatives, they
must be reassured ; “we do nothing that will
in any way interfere with the proper burial
of the body, or in any way be visible to either
the family or to the people viewing the body”.
This is not misrepresentation, inasmuch as
the body is prepared for burial by the funeral
director in such fashion that no one can de-
tect any evidence of the autopsy, providing it
has been properly done. In broaching the
subject of autopsies, I have found it advisable
to pick one responsible member of the family
rather than address myself to the entire group.
The question of religion comes up occas-
ionally, but has never been a serious stumbling
block in our hands. This question, particu-
larly as it applies to people of the Jewish
faith, will be fully considered in a subsequent
paper. Suffice it to say that we have found
that failure to obtain autopsies in Jewish
families is, in the main, due to a mental haz-
ard on the part of the person requesting per-
mission.
We are now ready to formulate a method
of procedure for obtaining autopsies. The
question naturally arises as to who shall make
the attempt. The ideal solution of this prob-
lem is to employ a person, preferably a physi-
cian either of the administrative or of the
laboratory staff, who has the ability to talk
convincingly and persuasively, and who can
develop a technic of approach. This, how-
ever, is beyond the financial reach of most
institutions, and therefore not feasible. The
most readily available person in the average
hospital for this purpose is the intern. He is
prepared for this duty by frequent talks on
the method of approach and the technic of
obtaining - postmortems. Whenever possible,
his presence is required in those instances
where the pathologist asks permission in cases
in which he has failed. By this method, I
have seen interns become very proficient in
obtaining autopsy permission. A most im-
portant requisite in the person requesting au-
topsy is that he, himself, be thoroughly con-
vinced of the importance and value of post-
mortem examinations. A rule in salesman-
ship to the effect that in order to sell an ob-
ject, the salesman must be fully conversant
with the idea or the thing he is trying to sell,
and must be sold on it himself, applies here
with equal force.
The pathologist must never relinquish his
personal interest in the autopsy, or there will
be an immediate and corresponding lag of in-
terest on the part of the intern, with a conse-
quent drop in autopsy percentage. I have
noted a decrease in our autopsy percentage
during my absence from the hospital for a few
weeks, or because of diversion of my atten-
tion by other matters. It has also been my ex-
perience that this percentage increased almost
immediately when I was again able to give my
personal attention and come in direct contact
with each hospital death.
August, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
639
After trying several plans, I have adopted
the following as a routine procedure :
(1) The intern who is called to pronounce
the patient dead must immediately fill out a
laboratory death report and send it to the
laboratory. This report contains information
which is of value in case the intern fails to ob-
tain permission. Data as to the cause of death,
operative procedures, length of the patient’s
stay in the hospital, and history of injury, are
included in this report.
(2) The intern must then approach the
relatives of the deceased for autopsy permis-
sion.
(3) Failing to secure permission, he must
bring the relatives to the office of the path-
ologist, who makes a further effort to obtain
such permission.
(4) If the death occurs during the night
and permission is refused the intern, the rela-
tives must be requested to return and see the
pathologist next morning.
(5) Permission secured, the laboratory is
immediately apprised of the fact, and it in
turn notifies the interested physicians as to
the time of autopsy. The autopsy is then per-
formed with the least amount of delay.
The worth of any plan is indicated by the
results it produces. Since the introduction of
this procedure at the Newark Beth Israel
Hospital, in 1926, we have had a steadily
rising autopsy percentage.
Hospital
Total
Total
Hospital
Death
Autopsy
Yrear
Deaths
Autopsies
Deaths Autopsies
percent
1923
T82
18
10%
1924
176
28
16%
1925
192
36
18%
1926
209
88
42.5%
1927
174
75
43%
1928*
332
192
258
168
64.5%
1929
374
262
303
212
70%
*In
February 1928 we moved
into a
new 400
bed hospital. This accounts for the rise in deaths
and autopsies.
We consider every case worth the attempt
even if we are sure to fail in our mission. For,
this failure is only temporary, as in each un-
successful attempt we sow the seed for future
success. There can be no doubt that some
measure of our increasing percentage in the
later years is due to the persistent, even
though in many instances futile, attempts in
the earlier years.
THE CONTINUED EDUCATION OF
THE DOCTOR*
John A. Hartwell, M.D.,
President of New York Academy of Medicine,
New York City
The invitation to address you, which I had
the honor to receive from Dr. Marcus, sug-
gested that I might speak along lines similar
to those presented to the New York Academy
of Medicine in the Presidential Address last
January. In the course of that discussion, it
was stated that some of the difficulties of
present medical practice could be relieved by a
return to an earlier practice when every fam-
ily had a definite medical adviser who was
trained in the field of general medicine, with a
sufficient knowledge of special fields to know
when the condition would be benefited under
the care of a specialist. This comment at-
tracted the attention of commentators. It was
made quite evident that the idea found a very
sympathetic response in the minds of many
individuals both in and out of the profession.
It is, of course, no new idea. The fact that it
was seized upon as the main text of the ad-
dress emphasizes still more that it has a great
hold upon the imagination.
The much more important theme which it
was designed to stress, dealing with the neces-
sity for the continued education of the doctor,
attracted very little attention. Even the as-
sertion that the New York Academy of
Medicine felt itself in a position to administer
an additional endowment of $2,000,000 in
carrying out this purpose received little com-
ment. In reviewing this, one may well con-
clude that those who commented upon the ad-
dress really placed their emphasis upon the
important point. It will be my endeavor to
present the subject to you in such a way that
you will recognize that the family doctor is
the essential thing in the continued education
of the doctor. I shall confine myself to a
consideration of the situation as it exists in
and around New York City. But you will
* (Read at the Fifth Councilor District meeting
of the Medical Society of New Jersey, Atlantic
City, April 10, 1931.)
640
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
recognize that the conditions discussed are not
local in their application.
There is little doubt in the mind of any one
who is giving thought to matters of health,
that the time is opportune for and even de-
mands an accurate evaluation of all factors
concerned in establishing and maintaining the
health of the individual and the community.
Paramount among these factors is the one
which, in the last analysis, any solution of
medical service to a community is dependent
upon, the science of medicine and its efficient
practice. Attention to organization, economics,
distribution, and all other factors is of value
only as it serves greater efficiency in medical
practice. It will be my aim to develop for you
one important phase of the subject which has
been receiving intensive study with us.
In a general way you are familiar with the
organization known as the New York Aca-
demy of Medicine, in which some of you may
be Fellows. It is not to be expected that you
should be informed as to the exact position
that it holds in New York City and it is im-
possible that you should be informed of its
aims and the means it is using to carry out
these aims. Since I am describing my subject
as it has been evolved by the Academy, I
shall ask your forbearance if I seem to unduly
stress its position in the plan.
Briefly, the Academy is a membership asso-
ciation of doctors at present numbering 1700
active resident Fellows with a less number of
Associates and nonresident members. The 1700
active Fellows are nearly all practicing physi-
cians. The Associate Fellows are engaged in
allied fields; Research Fellows are Doctors of
Medicine who are engaged in research in its
broadest terms.
The Academy has 3 fundamental aims: the
maintenance of a complete medical library, the
advancement of public health interests, and
the advancement of medical education. It is
the latter of these which particularly concerns
us at this time. And it is that phase of medi-
cal education which pertains to the doctor
after he has received his degree and license
to practice his profession which we would es-
pecially emphasize. But the Academy itself
is in no sense a post-graduate medical insti-
tution. We have no faculty; we have no
students enrolled in our courses. Nevertheless,
every activity which the Academy carries on
has for its object the continued education of
the doctor — the aim to improve the practition-
ers and their service to the community.
For several years a Committee on Medical
Education has been charged with this special
field and it has done splendid work in provid-
ing lectures and practical demonstrations at
the Academy. Some of you are probably fa-
miliar with the ■ annual Post-Graduate Fort-
night held each fall, and the Friday afternoon
practical lectures carried on through the win-
ter. To those of you who are not, and who
can afford the time to take advantage of these,
I would recommend a consideration of their
value, if I may do so with becoming modestv.
This committee is probably also known to
many of you through the Bureau of Clinical
Information and publications detailing the op-
portunities for study or demonstration in the
various hospitals. All these activities, we have
reason to believe, are of value to the doctor in
New York, whether residing there or making
a transient visit. But they lack one essential
thing: They are not parts of a whole; their
relationship oftentimes is not apparent and
oftentimes nonexistent. Within the past
half-decade the Academy has reached a full
realization that, if it is to enjoy its privileges,
it should accept its responsibilities. There was
brought to our consciousness the need for a
careful study of educational opportunities.
From whatever angle the question was ap-
proached, one constantly returned to the fun-
damental point that a great wastage of these
was taking place and that the recent medical
graduate was too much at the mercy of chance
for his continued education.
Our first approach was to determine the
qualifications which would properly entitle a
man to be considered as competent in a given
field. A subcommittee was asked to attack
this phase of the problem of specialism and
has spent much time and hard, conscientious
work. It has evolved a program for the min-
imum training and experience which a man
should receive before he can be graded as
qualified in a specialty. This was not so diffi-
cult to do because it was somewhat in the
nature of an academic pronouncement. The
August, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
641
weakness of the position became apparent,
however, when someone raised the question
as to how the individual doctor, who desired
to become proficient in any particular field,
should find the necessary opportunities to meet
the academic requirements. A review of the
courses given in the various hospitals of the
city, which had received the endorsement of
the Academy as being of value, showed that
they could by no means meet the requirements
of training men in a really efficient way. This
led the committee to lay down the following
statement of opinion:
“In order to raise the standard of their own
groups certain national organizations are de-
manding definite educational and practical re-
quirements for admission to membership. This
certainly prompts young men to seek the
necessary proficiency in order to qualify, but
the requirements in themselves do not provide
opportunities for study. Such opportunities
at present exist only to a limited degree. Only
a few universities have established complete
departments or separate courses, depending
on their facilities. Several of them offer an ad-
vanced degree for work accomplished. A large
number of hospitals, however, especially those
devoted to the specialties, have established
residences of from 1 to 2 years which serve
as training for that specialty. These various
efforts are very worthy and in their particular
locality those institutions are doing commend-
able work. The opportunities thus offered,
however, are inadequate for the total number
of men who want to, or who should, take ad-
vanced courses.”
“It has seemed to our committee that in
order to actually help along the cause of
medical education, especially in reference to
advanced or graduate medical education, it is
more important to provide opportunities for
study than to make demands on the young
medical man. On an undergraduate, we do
not simply make demands ; we provide the
medical school in which systematized courses
are offered which make it possible to pursue
an orderly, well arranged course of studv, and
then at the end of 4 years we demand that he
successfully pass in the prescribed subjects.
In the same way, interns are provided with
hopitals in which they continue their studies
under the direction of members of the attend-
ing staff. For the young man who wants to
become a specialist, however, no such
definitely arranged, orderly courses are pro-
vided. He has to shift for himself and try to
pick up whatever knowledge he requires to
perfect himself in his chosen field. It is time
to assume a helpful attitude toward these
men. We should provide opportunities for
study and practical work, carefully and sys-
tematically arranged, and after that has been
done we may make certain demands on them.”
“With this idea in mind we may ask our-
selves, and ask of this city, what we have
done to further the cause of graduate edu-
cation? Have we made the best of our op-
portunities? If we have not, what steps shall
we take to utilize the clinical resources of
New York City for the ultimate benefit of
the people, not only of New York City but of
a large part of this country?”
This extract from their report went directly
to the fundamental point in the discussion.
The question being raised, it immediately be-
came our responsibility to attempt to find the
correct answer. For this purpose the Board
of Advanced Medical Education was set up,
consisting of representatives of some 30 hos-
pitals in New York City which had shown
themselyes sympathetic to the idea of taking
part in the formal education of our medical
graduates. These representatives have met
on several occasions and have individually
worked on the problem of providing ade-
quate facilities so that the largest possible
number of medical graduates can be guided
and aided in their continued education, but
with the thought of the specialist always up-
permost.
You will recall that the original thought
only included formulating qualifications for a
specialist and expanded into finding means
whereby the doctor who was desirous of be-
coming a specialist could be provided with
those means. At the stage of the proceedings
at which we now arrived it became quite ap-
parent that any plan for the development of
specialists which did not take into considera-
tion the development of what we recognize as
the general practitioner, was lacking in an ap-
proach to the core of the matter. No one who
642
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 19 31
has written upon, discussed, or given real
thought to the problem of specialization has
failed to emphasize the grave danger that lies
ahead of the medical profession if its young
graduates are launched into special fields
without a broad fundamental training. A
training which, in fact, will make of them
competent, even though of limited experience,
general practitioners, able to efficiently under-
stand and take care of the major portion of
the illness of the community. In spite of this
clear understanding, it is quite apparent that
more and more the trend is toward early
specialization without sufficient basic clinical
training. The Academy therefore came face
to face with the entire problem of the con-
tinued education of the young graduate from
the time he receives his license to practice
until he is established in his profession, well
qualified for general practice and, if he so
elects, for specialization.
I will confess to you that when this thought
presented itself as the core of the problem, we
were somewhat staggered. The magnitude of
such an undertaking was immediately recog-
nized. The question at once was raised: “Is
the time opportune for attacking such a job?”
“And, if it be so, is there any hope that the
Academy of Medicine is in a position to lead
in its successful conduct?” We have not tried
to evade the issue, and alter careful consider-
ation we are now launched upon an attempt to
find the proper formula whereby such a goal
may be reached.
During the 2 years that this situation had
been developing, another thought had taken
shape in the minds of those who are devoting
their interest and time to this general subject.
This thought related to the question as to
whether we, in our organization, could take
an immediate forward step. Other committees
working on this phase of the project brought
forward a plan for a change of our internal
organization which has received approval of
the Academy upon recommendation of its
Council.
Heretofore, newly elected members of the
Academy organization, as mentioned above,
have been designated as Fellows and have had
the privilege of associating themselves with
all the activities of the Academy and of tak-
ing part in the administration and proceedings
of all its sections. No attempt was made to
carry these men forward in their educational
development as individuals except as they,
themselves, saw fit to develop ; and the Aca-
demy recognized no change in their status
after the time of their admission. Under the
new plan, a newly elected individual becomes
a member of the Academy. Upon his request,
he is assigned as a participator in some one
of the Sections. The activities of that Section
represent the line of development along which
he particularly wishes to travel. He is en-
tirely free to enjoy all the coordinate educa-
tional advantages that other activities of the
Academy and other Sections may afford ; in
fact, he will be encouraged to avail himself
of them. At such time as any such member
demonstrates to a specially selected committee,
of the older men of his Section of choice, that
he is proficient in his field, as proved by such
tests as this committee sees fit to establish, he
is recommended for promotion to Fellozvship
in that branch and, for example, becomes a
Fellow of the Academy of Medicine in
Otology. General Medicine, or General Sur-
gery, etc. Having done this, we are now faced
with the necessity of supplying the facilities
whereby the young man may carry forward
the needed development, for his promotion.
But the membership of the Academy in-
cludes less than 2000 of the total 12,000 prac-
titioners of medicine in the metropolitan dis-
trict. If the individual who has attained the
rank of Fellow in any particular field receives,
thereby, any advantage, it is only fair that the
Academy should extend the opportunities to
gain this advantage to members of the pro-
fession who are not on the Academy roll.
Similar opportunities should be furnished to
all young men of the profession, and, if they
so desire, we should certify when these young
men, whether or not members of the Acad-
emy, have attained that degree of proficiency
which, in the opinion of the Academy, entitles
them to recognition in a particular field. It
may well be that the Academy never will have
to render such service ; that the doctors not
belonging to the Academy will have no con-
cern as to whether it certifies to their qualifi-
cation or not ; but the situation is not altered
August, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
643
hereby, because the responsibility to provide
educational opportunities is none the less a
real one.
And now we return to the point where I
said that the comments on a previous address
stressed an incidental rather than the central
theme of the address ; but that on further con-
sideration I found that the incident was mas-
ter of the center. My original purpose was
to call attention to the need of the continued
education of the doctor; incidentally, I named
the general practitioners. Now, it is evident
that the continued education of the doctor can
only be approached through a consideration
of the needs of the general practitioner. In
other words, the latter is of necessity, from
the standpoint of sound pedagogy, the start-
ing point.
In New York City there is well over $100,-
000,000 invested in the education of medical
students and the advancement of the medical
sciences incidental thereto. When these same
students become doctors of medicine and re-
ceive a license from the state, they are en-
tirely dependent upon their own initiative as
to future events. After that time, neither
the university nor the state concerns itself
with their development. They are legally en-
dowed with full authority to undertake the
care of the sick. No one is concerned as to
whether farther training or experience qualify
them to minister to the pregnant woman, ex-
tirpate her uterus, determine the metabolic
rate caused by a clysfunctioning thyroid, or
trephine the eyeball for glaucoma. In blunt
English, it is no less than fool-hardy to neg-
lect the continued education of the doctor at
this most critical period of his development
when a reasonable amount of effort and the
expenditure of a relatively small sum would
guide him through this essential period to a
real orientation of his abilities.
While nearly every medical student, upon
receiving his degree, takes a hospital intern-
ship, some do not and it is a matter of uncon-
cern in the eyes of the state whether they do
or not. When they do, however, the educa-
tion received as an intern is largely a matter
of chance. It is well within the truth to say that
both the Board of Trustees and the medical
board of most of our hospitals are more con-
cerned with what the intern gives to the hos-
pital than they are with the education he re-
ceives from it. If he be a man of unusual
attainment and ability to absorb information,
his associations as hospital intern are of the
utmost educational value, provided the type
of work done by the hospital staff is of a high
grade. If, on the other hand, he be of aver-
age ability, it is quite probable that he will be
so overwhelmed with the routine work which
is required of him that he wall have little en-
ergy left to look after his educational inter-
ests. A number of interns of more than av-
erage ability have acknowledged that they are
so rushed and fatigued by carrying out their
prescribed duties that they have little incen-
tive to undertake serious study. They, of
course, pick up a very considerable amount of
practical education but a moment’s considera-
tion shows that, under proper arrangement,
the time spent in the hospital could be made
of much greater value to the intern. It is
true that the American Medical Association,
the Association of American Medical Colleges,
and the American College of Surgeons, have
each set up certain standards to which hospi-
tals must conform if they receive accredited
standing as suitable institutions for intern-
ship, but this represents only a beginning.
It is wrell within my memory when the lead-
ing hospitals of New Yovk City looked ask-
ance upon the admission of undergraduate
medical students to their wards and demon-
stration rooms for educational purposes, but
30 years have seen an enormous change in this
direction. When once it was pointed out to the
trustees of these institutions that they had a
definite obligation toward using the facilities
of their hospitals for the education of medi-
cal students, they welcomed the innovation.
Not only did they welcome it but they wmrked
hand in hand with the universities. They
sought and obtained enormous sums of money
for the specific purpose of providing such
education. To such an extent has this idea de-
veloped at the present time that every board of
hospital trustees feels the need of some affilia-
tion with a teaching institution, and the more
intimate these associations can be made the
better satisfied are the trustees.
If this change of front was accomplished
644
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
in the period of much less than a generation,
there is every reason to believe that when the
attention of hospital authorities is definitely
called to their further obligation toward the
farther education of these same men, the re-
sponse will be equally satisfactory and effec-
tive. The Board of Advanced Medical Edu-
cation, already mentioned, is a first step in
inaugurating this program.
Through definite effort and hard work by
the American Medical Association ; the Asso-
ciation of American Medical Colleges ; the
stimulation of some of the Foundations ; a
tremendous step forward has been made in
giving a satisfactory education to the aspirant
for the degree of Doctor of Medicine. It is
now equally important that forces should be
set in motion which will give definite form
to granting to this aspirant opportunity and
guidance through the years subsequent to his
receiving his doctorate of medicine.
I imagine that if any one of you were
casually asked to lay down a program for the
satisfactory, continued education of the doc-
tor through the first 5 years of his entrance
into the medical profession, you would fee!
that a free evening would permit you to satis-
factorily answer the proposal. From a rather
distressing personal experience and close ob-
servation of the experience of others, I am
inclined to believe that the result of your quiet
evening would be to find yourself in rather a
hopeless maze. In other words, it has become
obvious to those of us who have spent a good
deal of thought and effort upon this subject,
that the problem is hardly less difficult than
that which confronted those who wished to
put undergraduate medical education on a
sound and more or less systematized basis.
This was the work of many able men over a
period of years. It is quite probable that the
same amount of energy must be expended in
meeting the present problem. The first step,
obviously, is to demonstrate the need for it
and blaze a trail, the following of which may
reasonably be expected to lead us to our goal.
It is requisite that a careful evaluation be
made of the degree of proficiency at which
our graduates arrive 5 years after their grad-
uation, and the roads along which they travel
during those 5 years, in order that we may
reach an understanding of the relative pro-
ficiency of result and efficiency of method.
The hospital internship, as already pointed
out, needs careful revision as the first step. In
some cases the intern has an opportunity to
get a fairly broad vision of the field of clinical
medicine. He comes in contact with many
types of cases ; with men of stimulating
minds ; and he has an opportunity to compare
methods of arriving at correct conclusions and
obtaining definite results. In other cases, he
is placed upon a tread-mill where, by violent
physical effort, he finally reaches the top and
falls over the other side with a vision that
has been cramped within the narrow confines
of one field. In saying this I am not refer-
ring to the hospitals for special service only,
but to those covering more or less broad fields
where the intern is confined to a so-called
“straight service”. In still other institutions
the whole system connected with the intern’s
education is one of wasted opportunities. No
one makes it any particular concern to see that
the intern gets a fair deal; and often no one
is concerned to see that the intern really ren-
ders a service that prevents his falling into
sloppy, careless methods. He passes out of
the hospital door with a diploma bearing the
stamp of approval of the hospital authorities;
a document in many instances of real value
and representing hard endeavor and definite
attainment ; in other instances valueless. What
then? He may, by fortunate association, un-
usual ability, or pleasing personality, find
himself sought after and encouraged, placed
in positions where his growth is provided for
and where he is stimulated toward his contin-
ued education. On the other hand, lacking these
fortuitous advantages, he finds himself in a
precarious position of unfruitful struggle.
Possessed of energy and initiative, those be-
longing to the latter group, with much wasted
effort, ally themselves with various undertak-
ings, and valiantly push forward by the trial
and error method toward better things. Dur-
ing this period the great majority of them must
of necessity be chiefly concerned with earn-
ing an income. In many instances they are
forced to accept associations that are of little
educational value and giving little professional
experience, in order to meet the expense of
August, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
645
existence. This method of competition of
course has the advantage of bringing to the
top those of real ability and sound fundamen-
tal training. Rarely does such a one fail of
ultimate attainment of good education and
real proficiency in his profession. From this
and the first group many of the leaders come.
But what of the rank and file who are en-
dowed with sufficient inherent ability and
energy to become with proper encouragement
back-bone rather than head of the medical
profession? Lacking the qualifications for
leadership, they trail behind and are gradually
content to accept what seems the inevitable,
and struggle to form a clientele to which they
give a service largely determined by lack of
opportunity and from which they receive a
meager return. I do not believe I can be
challenged when I say that this group falls far
short of reaching that degree of proficiency of
which they are capable, under proper guid-
ance, stimulation and fair opportunity. Is it
asking too much that the head be concerned
with the strengthening of the back-bone?
Should not those who enjoy the privilege of
leadership be greatly concerned and lend more
than a helping hand toward this object?
This situation is also responsible for a great
many of our younger men launching them-
selves into a special field with very inadequate
previous training, because by this simple de-
vice they are able more promptly to get finan-
cial return and feel a certain relief from
economic burden. The public, as matters at
present stand, is of necessity poorly informed
as to the actual qualifications of many desig-
nating themselves as specialists. The tradi-
tion, deeply rooted in the human mind, that
special service is of special value and must
accordingly be paid for at special rates, yields
a higher immediate financial reward to these
men than to those who endeavor in broader
fields. This system, I repeat, is tragically
wasteful and unsatisfactory. We, as members
of the profession are naturally loath to squarely
face the fact that many of our Fellows are,
of necessity, lacking in the competency that is
obviously desirable. In doing this we are
open to the accusation of disloyalty and of
tending to inculcate in the public mind a lack
of confidence in the profession which we hold
in high honor. Some of the results and pro-
nouncements which have been made in con-
nection with the various studies to which I
have referred have brought forth this criti-
cism rather severely. I believe that this is
begging the question. Until the profession is
willing to devise and demand execution of a
plan whereby those of its members who desire
to specialize are encouraged and helped to the
utmost to attain their fullest development, and
whereby the public may have, through stand-
ards set up by the profession itself, access to
information which will enable them to know
who are the well trained, carefully prepared,
conscientiously performing doctors, we cannot
escape just criticism. The considerations here
set forth, I believe, have established the need
for continued medical education which I
stated was obviously the first step.
The next step I referred to as the blazing
of the trail along which we must travel to
satisfy the need thus proved. This, with our
present information, is by no means an easy
problem. Reference has been made to the
unsatisfactory and even chaotic condition of
internships as at present existing. It is here
that the young doctor gets his first real in-
dependent responsibility. It is here that he
gets his first continuous opportunity to ob-
serve illness in its entirety. It is here that he
is confronted with the actual application of
the principles learned in the basic sciences to
which he had some introduction in the clinical
teaching of his pregraduate days. It is of
the utmost importance that he should be under
the tutelage of men who are concerned with
his development; who feel a keen interest in
aiding this development and who take a satis-
faction in training those who will subsequently
fill their places. It is therefore quite as essen-
tial that the professional staff of the hospital
shall be organized as a teaching unit in the
same way that the faculty of the medical col-
lege is organized as a teaching unit. Much
thought and constructive effort has been
placed on the development of the college cur-
riculum and as at present administered in this
country we have a confidence that it is reason-
ably sound pedagogically. The same thought
must be given to developing the hospital or-
ganization in the same way. Allusion was
646
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
made to the fact that in too many instances
the intern is merely a cog in the routine ad-
ministration of the hospital without reference
to the return given to him. From the stand-
point we are now discussing we are desirous
of giving the interns a broad outlook upon
the field of medicine.
It would give me the utmost satisfaction if
I were able to present to you an ideal hospi-
tal curriculum including training in the var-
ious clinical fields, and the laboratories, as well
as giving due respect to the basic sciences and
literary attainment. Unfortunately, I find
myself totally unable to do this, but it is my
earnest plea that this question receive thought-
ful consideration and constructive efifort on
the part of educators and hospital admini-
strators. At the present time I am particu-
larly concerned in pointing out to you that it
is a crying need and that its adequate solution
is perfectly possible; as is proved by reference
to what has been accomplished whenever the
medical profession has put its mind seriously
upon solution of such a problem. I have al-
ready alluded to 2 examples, one having to do
with the tremendous improvement in our un-
dergraduate medical teaching, and the other
with the enthusiastic cooperation of the hos-
pital in this program when the need was
pointed out. Another example which I have
in mind pertains to a situation relative to this
whole subject which occurred in New York.
Some 15 years ago a number of observers
became concerned over the conditions that ex-
isted in many of the outpatient departments of
the city. An investigation of the matter showed
that this anxiety seemed to be well founded,
and the Committee on Public Health Relations
of the Academy of Medicine was given a sum
of $15,000 by one of the Foundations to make
a wider study of the problem. This resulted
in finding conditions that were totally unsatis-
factory and that were responsible for very
unfavorable educational factors for any voung
doctor who worked in these outpatient depart-
ments. Lack of facilities and organization,
overcrowding and rushed work, yielded an
inadequate return to the patient ; and resulted
in hopelessly careless and almost sloppy
methods on the part of the stafif. Stimulated
by this report, one of the Foundations gave to
the United Hospital Fund an additional sum
of approximately $500,000, expenditure of
which was entrusted to a Committee on Dis-
pensary Development for the purpose, in so
far as possible, of correcting these evils and
laying down a sound policy of development.
Very much was accomplished and the end is
not yet in sight because the Associated Out-
patient Departments are now organized on a
sound basis and are carrying forward the
general policy set in motion.
It is our hope that we may be able to pre-
sent the problem of the continued education
of the doctor; its present unsatisfactory posi-
tion ; the crying need for its correction and the
hope for definite results ; in such manner that
the ways and means may be found to give this
whole subject the study that it requires and
the help that must be extended to it if ad-
vantage is to be taken of the opportunities
that lie before us. In this way, at some fu-
ture date, it will be possible to present to you
that well thought out. efficientlv functioning,
curriculum for the hospital interns which I
have just regretted I cannot present to you
today.
Having carried our recent graduate through
his internship which, if this plan succeeds,
will be a direct continuation of his under-
graduate education, the even more difficult
problem confronts us of guiding him through
the subsequent 3 to 5 years. A certain num-
ber will continue their studies within the hos-
pital organization as an integral part of it,
in the position of residents, or other members
of the professional staff. Such, will inevitably1
be a part of the machinery having to do with
the problem of interns which we have just
discussed. These men will be the strong in-
dividuals who are endowed with those quali-
ties that fit them for leadership. The number
that can so continue their training is strictly
limited and constitutes a small portion of
those who have passed through the prelimi-
nary stages. What will become of the others,
assuming they have actually received sound
educational value while serving as interns?
The time has not arrived when they should
be left to shift for themselves in a hit or miss
fashion. In the 130 hospitals in New York
City, of which 30 have shown a sympathetic
August, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
647
attitude toward this whole subject by organ-
izing themselves into the Board of Advanced
Medical Education, there are sufficient oppor-
tunities to supply educational advantages for
practically the entire number of younger doc-
tors in the city who, at the stage of develop-
ment to which they will have been brought,
will have demonstrated fitness to go on in
the profession. Those who lack this fitness
should take the opportunity to recognize this
deficiency and turn their activities to other
fields.
In recent years, not only in New York but
in other communities, there has been much
agitation over what is loosely known as the
“open hospital”. A great deal of discussion
has developed along poorly thought-out lines
and has resulted in the advocacy of hopelessly
impractical and unproductive hypotheses.
Underlying this, however, is a perfectly sound
central conception, namely, that it should be
possible to so organize hospitals that their edu-
cational facilities shall be available to, as nearly
as possible, the entire community. Not infre-
quently the discussions have centered around
the economic injustice of limiting the facilities
of the hospitals to a certain so-called favored
few. In my opinion, this is unsound and not
helpful. I am strongly of the opinion that : if
we will furnish the educational opportunities
to our doctors; place before them a clien-
tele which is satisfied that it will receive com-
petent care, individually and -collectively ; show
that the public health interests will he ade-
quately considered and safeguarded; then, au-
tomatically, the economic problem of the medi-
cal profession will be largely solved. The pub-
lic will pay for such service gladly, and in
sufficient amount so that ever}- member of
our profession, who thoroughly and conscien-
tiously trains himself, will have ample oppor-
tunity to be adequately paid for his work. I
cannot expect full agreement with this con-
ception. But I am impressed with the fact
that, except in times of great stress, those
members of the profession who have had ade-
quate educational opportunities and have util-
ized these to the best advantage, receive suffi-
cient economic support for the services they
render to become respected and self-respect-
ing members of the community. Barring ex-
traneous misfortune, those who find life too
confined and cramped because of economic
pressure have failed in one or the other of
these requisites. Whether or not my con-
ception of this economic relation is true is
somewhat beside the actual matter under dis-
cussion. I feel absolutely sure of my ground
in saying that it is the duty of the leaders of
the profession to provide for the continued
education of the doctor; that the need for such
education is imperative ; and that the oppor-
tunities are at hand. My argument is that
these opportunities must be utilized to meet
the need.
I ask your indulgence for having made such
free reference to the Academy of Medicine
as concerned in this presentation, I felt the
necessity for doing so because my close asso-
ciation with the Academy has brought me
into contact with the subject and not because
I conceive the Academy to be an essential
part in the program. As far as New York
City is concerned, it possibly stands in a posi-
tion of strategic importance, but you will re-
call that I asked you to bear in mind that what
I had to offer, while referring particularly to
New York City, was equally applicable to
other communities.
In reviewing what has been said, I believe
you will see the justification of seeking a large
endowment fund to be expended toward the
attainment of the general purpose. I have
faith that if I, or any one else, be successful
in placing this program in its full force be-
fore those who are minded to furnish financial
support when a definite need is demonstrated,
that such support will he forthcoming in
ample amounts.
Our program then, is somewhat as follows :
A careful appraisal of all the internships at
present in the various hospitals of the metro-
politan district should be made. We already
have information as to the number of these;
the number of beds provided ; the fact as to
whether they .are so-called straight or rotating
service ; and in a very general way the type
of service that is offered. We must be inform-
ed, by an analysis made by trained and com-
petent observers, as to actual details. It will
648
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 19 31
be necessary to study the various hospitals
and learn the value of the educational train-
ing that the interns are receiving. While such
study is in progress, material will he gathered
to indicate how the various services can he
best utilized with the facilities at their dis-
posal to meet the object we have in mind.
Since these hospitals are exceedingly varied
in their activities, organization, financial status
and so forth, it is quite obvious that each one
will have to he considered as an entity. It is
probable, however, that they will fall into
very definite groups and that these groups
will he able, more or less, to follow one sys-
tematized plan. The material at hand from
such an investigation will give accurate infor-
mation as to how the laboratory service, and
even the basic medical sciences, shall he fitted
into the general picture. With such complete
information, one would be in a position to know
the type of educational training each hospital
can be developed to offer, and where needed
a definite program could he formulated as a
basis for obtaining the requisite financial sup-
port.
The hospitals of New York afford a large
number of residences, which are filled bv men
who have received the training of an intern.
Many of these are excellent educationally and
are much sought after. The majority of them
are in special fields and, as has already been
learned, they are often held by men who have
not had as much training in general medicine
as is desirable. In any case, the number of
such residences must be limited and will only
provide educational facilities for the more
favored and more competent. Therefore, the
problem of helping the rank and file of our
younger doctors, immediately after they have
left their internships, is one of utmost im-
portance in the whole plan. We know that in
the metropolitan district, and probably in
every community, there are vast educational
facilities that are inadequately used. This ap-
plies particularly to those institutions which
are not actively engaged in undergraduate
teaching. Even in many of those, the out-
patient department fails to yield more than a
small part of its educational advantage. Out-
patient departments properly organized and
giving true value to education are the very
best places in the world for a young man to
get invaluable clinical experience. Imperfectly
organized and badly administered, they may
well lie the graveyard of his aspirations and
the actual grave of his previous, carefully ac-
quired scientific trend. It seems to me that
the most vital element in this plan is concern-
ed with creating the will to teach. With this
developed, there can be no question that a
means of giving the earnest young doctors full
educational opportunities will be found.
While the use of the in-service of the hos-
pital to cover this special period is more diffi-
cult. I am of the opinion that the careful
study we are advocating will also find oppor-
tunity for a greatly increased use of this ser-
vice.
You will have recognized the validity of
our being staggered by the magnitude of the
undertaking we have in mind, when its full
import was presented to us. The fact that we
have already received, not only a sympathetic
but a really enthusiastic response from 30 of
our hospitals, and that a number of them have
actually set up splendidly functioning plants,
encourages us to believe that the will to help
already is in existence. This encouragement
gives us the impetus to go forward. The con-
summation of the plan cannot be reached dur-
ing the period of activity of myself or of
many of the men who are working with us.
But we intend to carry it forward far enough
so that the need will be fully demonstrated
and the road to follow plainly blazed.
WHAT THE PRESENT DAY PUBLIC
THINKS OF THE MEDICAL
PROFESSION*
Joseph C. Doane, M.D.,
Philadelphia, Pa.
This is an age of unrest in which incrim-
inations and recriminations in regard to po-
litical. sociologic and even medical questions
echo and reecho throughout the land. It ap-
pears to be a time when suspicion and mis-
*(Read at the Fifth Councilor District Meeting of
the Medical Society of New Jersey. Atlantic City,
April 10, 1931.)
August. 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
849
understanding fill the minds of men. The
medical profession has not escaped the often
caustic and usually unjustified criticisms of
persons who have fallen into the error of
formulating generalizations from fancied in-
dividual injustices. Let us examine 2 aspects
of the problem : How does the public regard
our profession? Is there any basis in fact for
this opinion?
There are those who have found that criti-
cal articles in regard to the profession gener-
ally bring a return in real money from a lay
press usually of lurid complexion. Hardly a
month passes without the appearance of con-
tributions in some of our better monthly jour-
nals relating to the cost of medical and hos-
pital care. The public avidly seizes upon
such statements and places in them often an
unfounded reliance. There appears no one
to refute or attempt to confound these criti-
cisms. The ethics of the medical profession
forbid such an effort at rebuttal. Nor does it
require a great deal of thought to convince
one of the shallow nature of many of these
writings. The daily press contains syndicated
columns on health, diet, drugs ad libitum — ad
nauseam. Some of the well known members,
if not known well in the scientific medical
circles, of our profession have learned that it
is easy to hire a secretary to turn out copper
plate advice to the ailing or those who believe
themselves to be so. They contend that the
money which they thus secure has equal pur-
chasing power to that which the ethical prac-
ticing physician earns with such difficulty and
at the expense of so much thought and
strength.
The doctor who has contracted the soul of
deadening disease, that of meddling in local
politics, and secures a public office, raises a
pseudo-scientific voice to warn a gullible pub-
lic as to the ills which may befall it. The
flamboyant quack with electric signs, and even
with a misleading name in the classified tele-
phone book, entices many of the unwary into
his usually bizarrely furnished suite of offices.
Here and there a sporadic attempt is made to
bring to judgment the unethical, illegal prac-
titioner. But just as certain as such efforts
develop, a hue and cry, often headed by mem-
bers of the intelligentsia — the pillars of so-
ciety— is raised. This is usually a cry of
persecution on the part of the jealous and
mercenarily minded practitioner.
The ways of the physician and the nurse
continue to diverge and there is much bicker-
ing and back-biting on the part of each of
these groups ; the former contending that the
latter desires to be educated in the same de-
gree as the physician, and the latter defying
the physician to prove that she is not a member
of a dignified profession and that she, there-
fore, should be coordinate with and not sub-
ordinate to the doctor. And yet, the great
majority of the members of the medical pro-
fession find no time for controversy and are
consumed in the business of caring for their
clientele. It must be said in all fairness to
the members of the nursing group that a great
majority of these women are fine, ethical and
efficient in their dealings both with the pa-
tient and the physician. Amid this chaos of
favorable and adverse comment, the patient
confusedly endeavors to decide which is the
way that will lead him to health.
It is a common comment for members of
the older generation to make, in regard to a
physician, that he is a gentleman of the “old
school”, inferring thereby that the physician
of other days possessed attributes which are
more or less strange to the relatively recent
practitioner of medicine. One’s mind reverts
to the personalities of these gentlemen of the
old school whom he has known and to the
lovable, yet often poorly organized life
which he led. The country practitioner of
a quarter of a century or more ago was likely
to live in one of the better homes in his com-
munity, to have an office which was conspic-
uous by its lack of tidiness; fur coats, medi-
cine bags, specimens of urine which were days
old, and unopened medical journals, doing
their part in the creation of an atmosphere of
disorderliness. His cellar was likely to be
stocked with vegetables which he had taken
as payment for professional services. A cer-
tain tendency to corpulency, a genial spirit, a
knowledge of the history and attributes of
members .of families in the countryside, and
even the genealogy of the farmers’ live stock
650
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 19 31
was not always beyond his knowledge. A man
whose regard for his own ease was nil, to
whom night and day were simply periods of
time ; a character loved by all who knew him
and yet one whose knowledge of medicine
had been largely self-obtained; whose ability
to explain phenomena which he saw was
frequently unorthodox. And when such a man
'full of years and honor put aside his medicine
bag and was gathered to his fathers, usually
his estate was of the most pitiful dimensions.
The size of his fees generally was not in any
true proportion to the ability of his clientele
to pay. He frequently kept no books and
assumed an air of having a favor performed
when bills were actually paid.
Contrast the medical gentlemen of the very
new school. For the past 2 decades it has
been the privilege of the speaker to contact
closely with many hundreds of the newer
graduates of medicine, to have an opportunity
to study their psychology, and to observe the
effectiveness with which they apply the knowl-
edge obtained in their medical schools. I have
the fullest admiration for the new generation.
These young men and women, having spent
$15,000 or more in securing a medical educa-
tion and practical hospital experience, often
look out upon the world as a financial oyster
which only requires aggressiveness, and fre-
quently self-exploitation, to successfully open.
They often are not content to spend much
time in dispensary work. They dislike night
driving and tedious midnight work. They
desire to quickly enter a specialty which re-
quires short hours and which returns large
fees. The study midnight oil is too often en-
tirely unknown to them except when refined
as gasoline. Office rents are high, motor cars
expensive to maintain, wives costly to support,
and they are not willing to labor through the
heart-breaking probationary stages of many
years of small time medicine in order to reach
the pinnacles which many of our medical fore-
fathers have so successfully scaled. And so
thejr endeavor to discover a short cut to medi-
cal eminence by proclaiming themselves
specialists in laryngology, gastro-enterology,
proctology, cardiology or dermatology. To be-
come an eminent internist, surgeon or con-
sultant requires more than mere word of
mouth proclamation, and so, many of our
younger friends are tempted to seek specialty
pursuits in which a certain amount of instru-
mentation is an essential. This very tendency
to find the easiest path has led not a few
physicians into the questionable avenues of
self-exploitation and of unethical advertising.
Is it any wonder, then, that from an observa-
tion of the acts of some members of our own
group, the public blindly inquires as to the
truth and as to the type of person from which
it may be obtained? This public has yet to
learn that not in all instances are those who
legally may append an M.D. to their names of
equal skill, ethics, or trustworthiness.
Again, there seems to have crept into the
medical fold, clad in the snowy garments of
the innocuous lamb, certain professional
wolves whose acts have reflected anything but
credit on the medical profession as a whole.
They appear with little notice in our large
cities offering courses of instruction in psy-
chiatry, treatment for varicose veins, and in
the cure of some of the hitherto little under-
stood ailments which have confronted the
practitioner. Their voices to the uninitiated
have fervent conviction as they appear on the
radio and their temporary offices are filled to
over-flowing with the guillible who have de-
serted the more modest waiting rooms of the
regular, more truthful, but less dramatic, prac-
titioners. They raise their voices high in
objection in legislative halls when any regu-
latory measures are proposed. They are able
to bring as evidence of their proficiency not
a few character witnesses who otherwise stand
high in their local communities. The public is
still more confused thereby as to the status
of the regular practitioner. And the regular
medical profession, due to its traditions of
silence and pacifism, remains dumb before its
accusers. Nor can it be said that the medi-
cal profession is entirely blameless in so far
as many of the charges which are laid at its
door are concerned. Let us inquire a little
more in detail in regard to the source of the
opinion which is held by some groups as to:
First, the lack of ethical procedure on the
part of physicians; second, that physicians
sometimes over-charge in a heartless way;
and, third, that medicine and medical proce-
August, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
651
dures are frequently impotent in the treatment
of disease.
There have recently appeared a number of
isolated articles in the lay press relative to
all of these matters. Specifically may be men-
tioned articles which have occurred within the
past year in the Survey Graphic, American
Medicine, Current History Magazine, Forum,
North American Review, Ladies’ Home Jour-
nal, Atlantic Monthly and others. There have
also been published a number of books, not-
ably, “Fads, Frauds and Physicians”, by one
Swann Harding; “Devils, Drugs and Doc-
tors", “Merely the Patient", as well as a num-
ber of other monographs in which the ques-
tion of operations, dealings with doctors,
treatment in hospitals, and the inefficiency of
nurses, have been treated in a more or less
jocose, and, to the writer at least, humorous
vein. Pursuing a steady course and with evi-
dent intent to furnish facts which will be use-
ful in solving this problem, has been the study
conducted bv the Committee on the Cost of
Medical Care. This committee consists of
distinguished representatives of the medical
profession — the American Medical Associa-
tion, American Hospital Association, Ameri-
can Nursing Association, American College
of Surgeons — as well as representatives from
the public generally. There have emanated
from this committee some exceedingly help-
ful and enlightening brochures relative to the
subject being studied. Many of the writings
appearing in lay journals have openly charged
the medical profession with commercialism
and with the employment of means for secur-
ing fees which are those commonly adopted by
the hold-up artist. Not a few of these articles
have suggested as a cure, the adoption of
state medicine in some modified form. For
example, in the October issue of the Atlantic
Monthly, Mr. Evans Clarke argues for group
practice, periodic examinations, and health in-
surance on the basis of fixed annual fees, be-
lieving that in this way medical bills might
be lowered. This writer objects strenuously
to the policy of charging a higher fee to the
wealthy than to the poor. A recent editorial
in the American Medical Journal, comment-
ing on this subject, remarks the impossibility
■of comparing good medical advice to the
millionaire, with the price of a hox of straw-
berries, and calls attention to the fact that a
lawyer certainly will charge a millionaire more
for making his will, than he would a man with
a hundred thousand dollars who insists on
describing the nature of his contributions
throughout 25 pages more than is required
by the will of the millionaire who gives it all
to his favorite friend. Frederick Collins, in
the Ladies’ Home Journal, turns his attention
to the cost of medical care and, like many
others, selects examples of the cost of hos-
pital treatment from the most exclusive insti-
tution in New York City rather than discuss-
ing the problem as it applies to .the poor.
When a lav person, or even a member of the
profession, attempts in a 10-page article to
solve economic and professional problems
which have troubled society for the past cen-
tury, there is little wonder that such authors
usually conclude by making themselves ridicu-
lous.
In a recent criticism of Swann Harding’s
“Fads, Frauds and Physicians”, Morris Fish-
bein, in the “Saturday Night Review”, con-
cluded that the author found the great
amount of material which he had gathered
difficult of mental digestion, and that the
volume which he has put out represents
what is known to gastro-enterologists as the
“indigestible residue”. He speaks of the strong
probability that, if state medicine is ever
adopted in this country, its physicians may
treat the Swann Hardings and others of his
ilk while the non-Babbittized individuals will
patronize independent physicians. However,
one cannot pass by such volumes as that of
Harding without some further comment, for
Harding has, with no little skill, placed his
finger on many of the sore points in our pro-
fession. He has developed an argument that,
while often fallacious in the extreme, is very
difficult to controvert. For example, in answer
to the question, “Do Doctors Often Err?”,
he quotes articles by Dr. Joseph Collins,
Carl Henry Davis, Chairman of the Depart-
ment of Obstetrics of the American Medical
Association. John B. Carnett, James T. Case,
Ochsner, Mayo, Robinson, Alvarez and many
others who have frequently admitted the im-
possibility of diagnoses and the inefficacy of
652
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
drugs and surgery in many conditions. More-
over, this writer invokes the Gospel of St.
Mark, as follows : “And a certain woman which
had an issue of blood for 12 years and had suf-
fered many things of many physicians and had
spent all that she had and was not bettered
but rather grew worse” — to prove that the
scourge of the ineffectual physician is as
old as Christianity. Then he lashes the tonsil
operator with unabated vehemence. He cas-
tigates the surgeon who removes innocuous
appendices. With righteous zeal, he flays the
doctors and the hospitals which over-charge.
Not stopping in his concluding chapter for
breath, as a climax to his major opus, he con-
cludes that the solution to all these injustices
lies in the adoption of the principle of state
medicine. Such an attack on the 120,000
physicians in the United States, while unjusti-
fied, is dangerous because it sows in the minds
even of thinking people the seed of doubt as
to the ethics and the effectiveness of their own
physicians whom they have trusted for many
years. Has it come to a pass where the fine
personal relationship of which our profession
is so proud and which has always existed be-
tween patient and physician is disappearing by
the changing circumstances of a newer age?
A young practitioner of medicine recently re-
marked to me that it is impossible now for
any physician to speak of a family as in the
somewhat proprietary sense, for a patient in
his charge today may be waiting in the office
of another physician tomorrow. True it is
that with development of the belief, in the
minds of many, that the neighborhood doctor
is effective only in treatment of minor ail-
ments, there has arisen the idea that, whenever
serious diseases develop, a consultant— a pro-
fessor in the words of the substratum — must
be secured. This is more than a casual hap-
pening. True also it is that the distin-
guished consultant from a downtown office,
by word of mouth or shrug of shoulders,
too often impresses the family with the
futility of their erstwhile trusted physician.
Such consultants, while often able to furnish
helpful information, are of the type which
deserves to be required, in the language of
the police, to go back to pounding a beat.
There is no more cruel and inexcusable act.
The fees of the consultant are not always
just. and. while the family often secures a
peace of mind by being assured that their
physician is efficient, the amount of finan-
cial return which the latter receives is usu-
ally exceedingly disproportionate to that
of the consultant. In an instance recently
brought to my attention, a young physician
secured with much difficulty $50 for 25 visits
to a pneumonia patient while the consultant
earned S50 in 10 minutes, adding nothing ex-
cept the information that the patient was suf-
fering with a right lower lobe pneumonitis.
To be sure, the cost of living today has in-
creased several hundred per cent over that of
half a century ago. The public demands the
specialist and yet objects to paying for
specialty information. It is true that oft-
times such information emanates from an in-
dividual who is incapable to furnish the type
of service which he purports to give. Many
sins have been committed and are being com-
mitted in the name of electrocardiograph, for
example. The flashing of sparks, the darken-
ing of the room, the long and cryptic films
are all impressive. W hile not depreciating the
value of electrocardiography as an adjunct to
the careful clinical study of the patient, one
wonders whether the information furnished
by some of these specialists, which may range
from the number of days which the patient
has yet to live to the exact date on which the
valvular defect occurred, is always reliable.
Throughout all of this play-acting, this dis-
sembling, the quiet, unassuming, scientifically
trained and sober-minded doctor is likely to
lose ground. Such a physician recently re-
marked to me that self-efifacement had no
place in the present day medical profession
and that it is a virtue which becomes only the
clergy.
There is much demand being made by social
workers and even by physicians and hospital
managers for provisions for the care of the
middle class. The greatest experiment of this
type which is being carried on in this coun-
try appears to be at the Massachusetts Gen-
eral Hospital where a $2,000,000 plant has
been constructed to furnish private rooms for
this economic class. Indeed, a generous Foun-
dation has under-written the loss on this ven-
August. 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
ture to the extent of $35,000 annually. One
wonders whether the middle class is doing as
much as it can to care for itself. It is a trite
observation that this so-called white collar
class finds money to purchase furniture,
pianos and automobiles when the doctor is
being asked or required to wait for the pay-
ment of his bill. Some doggerel describing
this situation comes to the mind of the writer
at this junction:
“Send for the doctor, dearie;
Tell him to not be late.
We will pay the butcher, the baker
And candle-stick maker,
But the doctor, oh 1 my dear, the
Doctor will have to wait.”
( 1 ) The difficulty of our present day situ-
ation is that we are using the wrong sort of
lens to inspect the question of medical service
to the community.
(2) The need for a period of readjustment
along all lines.
(3) The cure? purge our ranks. The place
of the county medical society? It should act
as leader in public health and ethical prob-
lems.
(4) Better medical attention from the
standpoint of teaching young doctors medical
economics and details of their relationship to
the community.
(5) The fallacy of the medical guild and
of state medicine.
(6) Get someone else to fight the battles of
the doctors.
(7) Most people believe in the doctor,
although they may not be able to state it so
beautifully as did Robert Louis Stevenson :
“There are men and classes of men that
stand above the common herd : the soldier, the
sailor, and the shepherd not infrequently; the
artist rarely; rarelier still, the clergyman; the
physician almost as a rule. He is the flower
(such as it is) of our civilization; and when
that stage of man is done with, and only re-
membered to be marveled at in history, he
will be thought to have shared as little as any
in the defects of the period, and most notably
exhibited the virtues of the race. Generosity
he has, such as is possible to those who prac-
tice an art. never to those who drive a trade ;
discretion, tested by a hundred secrets; tact,
tried in a thousand embarrassments ; and what
Go 3
are more important, Herculean cheerfulness
and courage. So it is that he brings air and
cheer into the sick-room, and often enough,
though not so often as he wishes, brings heal-
ing.'’
THE NOISES OF CIVILIZATION AND
THEIR EVIL EFFECTS*
Walter A. Wells, A.M., M.D.,
Washington, D. C.
Many thousands of years ago man became
differentiated from the other animals about
him by his utilization of tools. Very crude
they were in the beginning but they enabled
him to overcome his enemies, secure food,
and live with a little less effort ; the first step
in the course toward civilization. It was by
tools, therefore, that he began, figuratively
as well as literally, to make some noise in the
world.
Although it must have been evident that it
was by implements and machinery that man
extended the power of his arm and gained
mastery over Nature, it seems strange to us
now, in this age of machine civilization, that
so many centuries passed with so little im-
provement in this regard. Each generation
seemed perfectly content with what it had
inherited from the generation preceding. It
was really not until the latter part of the
eighteenth century that the world seemed to
become conscious that the forces of nature
might be turned to the practical uses of man.
Then began that ferverish search into her
mysteries which resulted in many wonderful
discoveries. Invention quickly followed dis-
covery and when it was seen that labor saving
devices brought to the owner wealth and
power, there sprang into existence a multi-
plicity of machines.
Water power was first used but soon gave
way to the more efficient power of steam, and
then later was added the wonder-working
*(Read at the 37th Annual Meeting of the
American Laryngological, Rhinological and Oto-
logical Society and presented for publication in
our Journal subsequent to its appearance in the
Annals Otol., Rhinol, and Laryngol, March 1931.)
654
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 19 31
power of electricity. Steam railways began
to traverse the land ; steam ships to plow
through the waters of the rivers, lakes and
seas ; the cotton gin and the spinning jenny
were invented ; sewing machines appeared in
every household, and harvesting machines on
every farm. A new age, the age of ma-
chinery came into existence. A new era of
civilization was proclaimed throughout the
world.
Now, every machine with its improved
methods of production, and every invention
turned to use for the manufacture of goods
or the transportation of man and material,
brought also into existence more and worse
noises. In the excitement of the newly gain-
ed wealth and power and of the dazzling new
civilization, little heed was paid to the per-
nicious noises which accompanied. It is sig-
nificant, however, that it was about this time
we first began to hear of actual suffering by
man from such a cause. We need only to
mention as conspicuous examples, the names
of Schiller, Goethe, Carlisle, Dickens and Her-
bert Spencer, illustrious geniuses of that era,
whose lives were made miserable by noise.
With the profits and conveniences of the new
industrial civilization came new afflictions
chargeable to the same account.
In the early and simpler world, when man
lived chiefly by the pursuit of agriculture, the
sounds of the world were almost only those
which emanated from animate and inanimate
nature. It has always been maintained, and
we believe rightly, that the sounds of inani-
mate nature are good for the body and re-
freshing to the soul. However unpoetic the
mind, one can hardly fail to experience pleas-
ure in the sounds of rustling leaves or of
flowing water. There is no doubt that much
of the charm of music is derived from the
conscious or unconscious suggestion of these
elemental sounds, and we find therein the best
explanation of why music soothes and exhil-
arates the spirit. In strong contrast to the
pleasing sounds of inanimate nature, are the
disagreeable sounds of artificial origin, which
we call noise ; and whose effect is to ruffle,
irritate and annoy.
Scientifically considered, music is character-
ized by a succession of regular, rhythmic vi-
brations ; noise, by ,a medley of vibrations
without order or uniformity. The contrast
may be strikingly shown by graphic tracings.
The musical note is represented by regularlv
recurring, perfectly formed curves; noise by
crooked, irregular, crumpled lines. The noise
of the world may lie roughly classified as or-
iginating from the following causes: (1) Ani-
mate nature; (2) war; (3) building and con-
struction; (4) traffic and transportation; (5)
manufacture; (6) commerce; (7) communi-
cation.
Our forefathers, who tilled the soil, hunted
wild and took care of domesticated animals,
were not altogether free from the annoyance
of noises. The sounds emitted by animals are
in the main for 2 purposes — to attract mates
and to terrify enemies. The first are intended
to be pleasing, and in truth we do not, as a
rule, find disagreeable the cooing of doves,
the neighing of horses, or the mooing of cows,
and the warbling notes of song birds give
almost universal delight. But we may class
as noises the sounds animals make to terrify
and drive away foes ; the roar of the lion and
the growl of the tiger must certainly be so
considered. Much, however, depends upon
the time and place. The distant bark of a
dog is sometimes good to bear, but coming
from the back-yard in the early morning hours
it is an unpleasant noise.
War, since earliest times.* has been a pro-
lific source of noise. The warriors of old were
spared the terrific din of heavy artillery, but
they managed somehow to make enough noise
to “fright the souls of fearful adversaries”.
The noises of modern warfare are stupendous
and overwhelming, and their harmful effects
fall upon friend more than upon foe.
The noises incident to construction are
probably the most intense of all those to
*A graphic account is to be found in Scripture
of the successful employment of noise in war for
the purposes of " schrechlichkeit "For the Lord
made the host of Syrians to hear a great noise of
chariots and a noise of horses and they said to
one another, Lo the King of Israel hath hired
against us the Kings of the Hittites and the Kings
of the Egyptians to come upon us; wherefore they
arose and fled in the twilight and they left their
tents and their horses and their asses, even the
camp, as it was and fled for their life.” Second
Kings, 7:6.
August. 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
655
which the modern city dweller is exposed.
It is said that erection of the great steel sky-
scraper takes a heavy toll from among the
workmen because of the extra-hazardous na-
ture of some of the work. There ought also
to be charged to it certain ills of which no
reckoning is usually made, but which affect
not only those engaged in the work, but also
the innocent neighbor and the disinterested
by-passer. There is nothing that better be-
speaks the wisdom of Solomon than the pre-
caution he took for the noiseless construction
of his famous temple. As his own pastoral
people were unskilled in such work, he en-
gaged artisans from Tyre and Sidon, but he
directed that all the work of cutting and
chiseling of the stone should be done a dis-
tance away so that, as it is written, “no sound
of hammer or ax or any tool was heard in
the house while it was building”. Would that
we had a Solomon to protect our people from
the ruthless builders in our great cities. He
would save many from ruined ears and shat-
tered nerves. It is not now a matter of such
mild noise as that of hand-plied hammer and
ax and saw, but the unearthly din of the rock
drills, excavating shovels, pneumatic ham-
mers and, worst of all, riveting machines.
Scientific measurements have been made
throughout the city of New York of noises
from different sources, and the results record-
ed in terms of the decibel. The noise of rivet-
ing measured at close range registered 100
decibels — which means that the intensity of
this sound was 10 billion times the minimum
sound that can be heard.
In the survey of New York City noises,
made by the Noise Abatement Committee
specially appointed to study the question and
report on these matters, it was found that
36% of the noise was chargeable to traffic and
16% to transportation. As a matter of fact
it seems impossible to separate these items.
Vehicular traffic is now almost altogether a
matter of automobiles and naturally, with 20,-
000,000 of them in this country, with their
horns, sirens, whistles and bells constantly on
the go, they are a prolific source of noise. The
worst offenders are the heavy buses, vans and
trucks, especially when running on solid tires
or with loose gears and chains. The noisiness
of city streets is tremendouly increased by the
public carriers, the surface trains, the elevated
and the subway. The clatter and clang of
street cars are harmful as well as disturbing
to those who have to live along such routes,
and conversation and business have often to
be suspended at the moment of cars passing.
The noises of the subway and of the elevated
are of even greater intensity at close range,
and they contribute much to the general street
noise.
According to Dr. E. E. Free, the noisiest
corner in the world is 34th Street at 6th Ave-
nue, New York; a location, as he remarks,
cursed with 3 main streams of street traffic, 3
surface car lines and 2 tracks of the elevated
railway. There the intensity of the average
noise is 100.000 that needed for hearing. Dr.
Harvey Fletcher, in his thorough, painstak-
ing measurement of New York City noise,
found corners in which at times even this
noise is exceeded.
The noise of steam railway transportation
has in recent years been improved somewhat
by better road-beds and better built cars. The
noise of freight cars, especially when backing
and filling on a side switch, with the coupling
and shrill whistles of engines, leaves, however,
much to be desired. The noises of water
transportation are in general not so bad as
those of land but for persons who live near
water fronts the fog-horns and whistles of
tug-boats and other craft are often very dis-
turbing, especially at night. The newest ar-
rival in the field of transportation is the aero-
plane, with a noise all of its own, and usually
of such intensity that passengers and pilot
must wear ear-plugs and forego all conversa-
tion while en route ; a noise of such a stunning
effect to some that they remain deafened for
many hours after landing.
Among noises coming under the head of
commerce we would especially mention those
connected with collection and delivery of mer-
chandise ; the throwing about of boxes, bar-
rels and tin containers, are only a few that
could be mentioned. The early morning call
of the ice-man and the milk-man are particu-
larly dreaded in some quarters. We must also
include here the weird calls of hucksters, the
hoarse shout of news-boys calling extra edi-
656
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
tions, the bell ringing of scissors grinders — all
noises with which most of us would willingly
dispense.
A recent great increment in the noises of
civilization is attributable to the coming into
common use of measures for more rapid com-
munication, such as telegraph, telephone and
radio. The click of the telegraph key or the
bell ringing of the telephone seldom bother
anyone except those directly in the room, but
the squeak and squawk of the radio are often
heard through the partition walls of an apart-
ment, and sometimes carried out of the win-
dows to the neighbors across the street or
people on the sidewalks below. Under this
head we must also include the typewriter, an
instrument of communication in very common
use. Notwithstanding some decided improve-
ments that have been made in this regard most
offices still cling to the old style hammer-
blow tvpe of instrument, either by reason of
habit or on the score of economy. When
health is considered, however, that is poor
economy. Indeed, we doubt not but that
business economy would be better served by
a quieter environment, for under the influence
of distracting noise efficiency is everywhere
reduced. Errors are likely to creep into ac-
counts, letters are formulated with more diffi-
culty, and conversation with clients may be
less convincing.
We have not, of course, named all the
troublesome noises there are, but enough to
be sure to indicate that this present work-a-
day existence of ours is indeed very full of
noise. The past decade or so has been mark-
ed by a very extraordinary advance in science
and multiplication of machinery and it was in-
evitable that noise should correspondingly in-
crease. The most alarming fact is that noises
have not only increased in number, variety
and intensity, but also in extension. Formerly
confined to certain special localities, such as
factories, railroad centers, and cities in dis-
tinction to the country ; now, thanks to the
automobile, the flying machine, the power
plant and the radio, the dominion of noise has
been enormously extended. Indeed, the noises
of civilization now not only cover the face of
the earth but they fill the air above and even
invade the water under the earth. There was
a time when the tired city dweller might eas-
ily find a sequestered nook in the country
where all was quiet, restful and serene, but
where can one go now and not be obliged to
hear raucous horns or screeching sirens, or
(if by the waterside) the eternal chug-chug
and shrill whistle of motor boats. There is
nothing more certain than that one will have
a continual treat of filtered jazz music from
the inevitable radio, and it is always possible
that he may have forced upon his ears the
thunderous roar of low-flying planes, which
are no respecters of persons and are not re-
stricted by the laws of eminent domain.
Evir. Effects of Noise on Health of Man
The evil effects of noise may fall chiefiv on
the auditory apparatus itself, or chiefly on the
general nervous system. The hearing organ
may be affected in one of 3 ways: (1) by
suffering loss of function; (2) by developing
a state of abnormal sensitiveness; or (3) by
acquiring a special tolerance or habituation
to the noise irritant.
It is a fundamental physiologic law that an
organ treated to an excess of its proper stim-
ulus must either adapt itself thereto or suffer
harm. The auditory sense, phylogeneticallv
considered, is the most recent arrival in the
family of special senses. It is, therefore, of
frailer texture and endowed with a feebler
resistance than any of the others. This is no
doubt the explanation of the well attested
clinical observation that when the eighth
nerve, composed equally of auditory and
vestibular fibers, comes under the influence of
toxic material in the blood, the former proves
regularly to be the more vulnerable and it
makes likewise understandable the fact that
the auditory function can readily suffer from
over-stimulation by sound.
It is pertinent in this connection to call at-
tention to the comparatively unprotected state
of the hearing organ. Its situation deep with-
in the petrous portion of the temporal bone
is indeed a good guarantee against ordinary
gross traumatisms, but we refer to the help-
less exposure as regards the vibrations of
sound. The retina is protected by eyelids,
which close voluntarily or involuntarily,
against injurious visual stimuli, but there are
August, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
657
no earlids to save Corti's organ either night
or day from hurtful noise that fills the sur-
rounding air. The tympanic muscles are per-
haps intended to have a function somewhat
analogous to the ciliary muscles but, if so, they
are obviously inadequate, because of their
feeble action and their easy susceptibility to
fatigue.
Deafness is not a common result, notwith-
standing the frequently expressed opinion of
those who are waging war against the noise
nuisance. It can certainly occur when the
individual is exposed to an intense noise, at
close quarters over a long period. Such con-
ditions sometimes present themselves in cer-
tain occupations, like the boiler-makers’ trade,
where deafness is due to a nerve degenera-
tion of high degree, and incurable, and ap-
pears in a large proportion of cases. It is a
well founded observation, however, that such
results occur only when the prevailing notes
of the noise are in a high pitched register and
of a very disagreeable character. Some in-
teresting experiments have been made by
Witmaack, Yoshi, Siebenmann and others,
of exposing animals continuously in close
proximity to intense sounds of various kinds
and later examining postmortem the deafened
ears. Degenerative changes were found in
Corti’s organ, and it is notable that they were
•chiefly located, in confirmation of Helmholtz
doctrine, in parts of the cochlea correspond-
ing with the sound pitch employed.
Sometimes the middle, rather than the in-
ternal,, ear is affected by excessive noise. Sud-
den intense explosives, • such as those made
with bombs and heavy machine guns, may
spend their force on the middle ear, causing
rupture of the tympanic membrane and hem-
orrhage. This may act as a safeguard against
injury to the labyrinth, but labyrinthine con-
cussion may, nevertheless, occur at the same
time.
Now, the noises to which the average citi-
zen is exposed are seldom of such nature and
intensity as to produce deafness. The usual
city noise, for instance, is that of a continuous
roar and hum, with only occasional severe ex-
acerbations. What happens to the individual
much exposed in this way is one of 2 things :
either he develops for the noise excessive sen-
sitiveness, or he develops an especial tolerance
— auditory hyperesthesia, or the noise habit.
Auditory hyperesthesia is a much more com-
mon affliction than from the literature of the
subject we would be led to believe. If the
otologist would more often follow the clue
given by the patient who casually, mentions
that shrill sounds produce on his ear a de-
cidedly painful impression, and that even or-
dinary sounds are distorted into unpleasant
clangy effects, the diagnosis would be made
oftener, I am sure, than it is.
Annoying tinnitus is also a frequent symp-
tom, and in some cases even static functions
are affected, as evidenced by more or less ver-
tigo. These cases, uncomplicated by a middle
ear disease, require not local treatment but a
prolonged rest in a quiet country place if such
can be found. When obliged to remain in
the same environment, much help can be ob-
tained by keeping the ears continually plugged
with cotton or wool moistened with glycerin.
Middle ear inflammation may be present at
the same time, associated with hyperemia,
which tends to exaggerate the sensitiveness.
In such cases, of course, the middle ear af-
fection should have appropriate treatment,
which is often found to be quite helpful.
Noise h.abituation. Since it is exceptional
for the ordinary noise of our environment to
be of sufficient severity to produce deafness,
adaptation may take place by development of
a certain tolerance for the customary noise,
which eventually may take on the form of a
regular noise habit. There is no question that
many persons do become so habituated to
noise, and so dependent upon it that they seem
unable to get along without it. It is not an
uncommon experience, as most of us very well
know, for persons who have lived a long time
in the midst of city noises to find, on suddenly
being translated to the quiet of the country,
that the silence is actually oppressive. They
are unable to1 sleep, and are restless and un-
happy until back again where they can hear
the noise of the city streets. There are many
persons of whom it may be said that they de-
velop an actual fondness for noise, a ptupo-
philia, and so are constantly seeking pleasure
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1031
65 8
in noisy excitation. In some cases the ten-
dency goes on to the extent of a craze or mad
craving for noise, a veritable ptupomania.
This is a malady which we fear has become
already alarmingly common in America and
which we believe explains the widespread
popularity of the degenerate jazz.
Disorders of the brain and nervous system.
The injurious effects of sounds are in many
instances not confined to the ear but pass over
to the brain and general nervous system.
Sounds affect us through the association of
ideas. The soothing or soul-stirring influence
of music is explicable, as we have already in-
timated, by the conscious or unconscious sug-
gestion of the sounds of inanimate nature.
Noise, on the other hand, may be hurtful by
the suggestion of physical harm and suffering.
Drawing the finger nails over a rough sur-
face, or biting on a gritty substance, is accom-
panied by sounds peculiar to these acts. Such
a sound, when reproduced naturally, suggests
injury to the human organism and gives a
disagreeable impression. There is recognition,
by inference of association of ideas, when
certain noises are spoken of as harsh or
grating, and even more directly when de-
scribed as having the effect of “making the
blood run cold", or causing “cold chills to run
up and down the spine". Another reason to
account for the disagreeable effects of noise
upon the nervous system, is the arousing of
what is called the “fear-reaction", an instinc-
tive reaction inherited from our remote an-
cestors who had to be always on guard against
surrounding enemies and to whom certain
menacing sounds were a signal of impending
danger. This applies especially to sharp,
sudden sounds, which break unexpectedly
upon an otherwise comparatively cjuiet en-
vironment. We know how the effect of such
sound is, to make us start.
Because of the importance of the associa-
tion of ideas, we can understand that the ner-
vous system is concerned not so much with the
intensity of the sound — the number of de-
cibels that it registers— -as with the disagree-
able character and the suddenness. A number
of experiments have been made which show
that noises have a decided effect on the vital
functions of man and the lower animals.
Gouty and Charpentier found that noises such
as the slamming of a door, caused in dogs a
1 0c/r rise of cardiac tension with acceleration
of the pulse ; and Landis observed in man a
rise of systolic pressure of 20 mm., as a result
of the explosion of a fire-cracker. Particularly
interesting were the experiments reported by
Dr. Foster Kennedy concerning patients in
the hospital who on account of accident or
operation permitted observation of direct ef-
fect of sound on brain circulation. It was
found that explosion of blown-up paper bags
caused a notable rise in intracranial pressure.
Experiments have been made by Dr. J. B.
Morgan, of North Western University, by
Dr. A. T. Poffeberger, of Columbia Univers-
ity, and bv Donald A. Laird, of Colgate Uni-
versity, to determine, especially from the psy-
chologic point of view, the effect of intense
noises on mental functions and incidentally its
influence on other body functions. In prac-
tically all these experiments the effect was a
speeding up of the motor, cardiovascular and
respiratory functions ; ancl in the performance
of various mental operations there was an un-
due strain, fatigue, and loss of energy in com-
parison with silent conditions. Such experi-
ments form a basis for explanation of the
neurasthenias and psychasthenias which are
reported by authority of clinical experience.
It is worth mentioning that from various
parts of the country reports have come re-
cently which indicate an unfavorable effect of
loud noises on the reproductive functions.
One farmer reported that because of the near-
ness of an aerodrome, and the terrific noises,
the cows on his farm failed to calve and gave
less milk ; another threatened to bring suit
against a company because the egg-laying of
his hens had been reduced to nil. I know of
no experiments directly to test the effect of
sound on reproductive function, though Dr.
Laird has observed that the growth and de-
velopment of rabbits in noisy cubicles was
decidedly poor as compared to the control, and
he is of the opinion that severe noise may
unfavorably affect the nutrition of infants.
It may or may not lie significant that there
has been a steady decline of the birth rate in
all civilized countries dating from the begin-
ning of the machine age. In England and.
August, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
659
Wales the birth-rate in 1877 was 36.2 to every
1000 of population; in 1928 it had fallen to
16.7. From similar high rates it fell in the
U. S. to 18.2; and in France to 18.2, Ger-
many to 18.6. In other countries, where ma-
chine . civilization is not a factor, the rates
have remained high; in Ceylon, for instance,
in 1928 it was 40, in Egypt 43.3 per 1000.
Of much greater importance than the fall-
ing birth-rate is the rising incidence of mental
diseases, which has been noted in all civilized
countries in recent years. This has gone on
until at the present time in the United States,
for example, we are confronted by the appal-
ling reality that inmates in the institutions for
the insane and feeble minded outnumber those
hospitalized for all other disabilities combined.
The significance of this increase in relation to
noise cannot be ignored because of the ex-
perimental proof, on the one hand, of the
influence of noise upon brain function and,
on the other, the clinical testimony to the fact
that mental derangement is often directly
traceable to this cause. One factor, as already
mentioned, is the strain which induces mental
fatigue and irritability; another, no doubt, the
loss of sleep and rest which have ever been
recognized as potent causes of mental break-
down.
Consideration of these factors, pointing to
the detrimental influence of noise upon in-
tellectual faculties, brings us face to face with
the question whether noise, the inevitable
accompaniment of higher civilization, should
not be accounted civilization’s worst enemy.
Advance in science is made possible only
through sustained thought and concentrated
attention. Noise scatters thought and is
an effective hindrance to the operation of
attention. Rest and sleep are fundamental
necessities for the continuance of healthy
mental activities. Noise produces fatigue and
irritability and then denies the sleep which
is more than ever needed to restore mental
function. It is, then, an inescapable conclusion
that noise, the by-product of civilization, un-
erringly tends to impede and destroy those
very intellectual functions upon which prog-
ress depends. It is the ash \\4iich, unremoved,
will eventually extinguish the fire.
The very discouraging thing about this
positive evil which we call noise is that, bad
as it is, the future looks worse. Edison, re-
ferring to the future of the cities, says that
city noise must inevitably grow greater and
that the man of the future generation will as a
consequence be deaf. Without accepting the
pessimistic doctrine that the ultimate destiny
of the city dweller is deafness, Ave have no
doubt that the noises of the civilized world
are steadily on the increase, for not only are
new machines being made daily, with a conse-
quential increment of incidental noises, but —
and this is the crux of the matter — machines
are being now deAnsed and coming into use
which make the increase or the magnification
of sound their main or primary purpose.
The most ingenious, perhaps, of modern in-
ventions are those which have to do Avith the
transmission and amplification of sound. For-
tunately for us, the sounds of our hearts are
not ordinarily heard and the contraction of
the innumerable muscles of our body take
place in silence. But it is now possible, by
means of a little disc held in contact with the
body, to cause the pulsations of the heart to
be heard throughout the room as the thump-
ing of a heavy hammer, and the contraction of
minute, invisible muscle cells, 1/5000 of an
inch breadth, to be audible as loud crackling
explosions. Is it not awe-inspiring, and per-
haps ominous for the future, to meditate upon
the possibilities if all the silent Avorld Avere
Avakened into sound?
A short while ago, Pastor Wagner, author
of the “Simple Life”, lamenting the noise and
bustle of the age, found consolation in the fact
that “after all, the realm of silence is vaster
than the realm of sound”. So, perhaps, it is,
but there is reason to fear that it cannot al-
Avays remain so, unless the efforts of science
to suppress noise can in the future be made
to keep step with efforts to create it.
There is need for arousing public interest
in this direction, for, notwithstanding the ac-
tivities of a committee here and there, marked
indifference to the subject generally prevails.
Let a new Avonder-making machine come to
light and you find always the interest in its
accomplishments easily blinds us to the evils
of its noise. The need, perhaps, is more acute
because of the increasing number of ptupo-
660
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
philiacs among us, who love noise not for
what it means but simply for noise’s sake. For
esthetic reasons alone, a strong sentiment has
been worked up to rid the highway of bill-
hoards and ugly signs which offend the sight.
Shall we be less active to get rid of noise
which not merely offends the hearing but in-
jures it and which may do harm to the health
of body and mind, and which furthermore
there is good reason to believe hinders the
future upward progress of the race?
The word civilization is said to be derived
from the word “quies”, meaning rest or quiet;
the idea being that through freedom from the
necessity of labor one secures leisure, rest
and quiet ; but the unexpected has happened
and there has come, instead, unrest, disturb-
ance and noise. Will it always be so ? Or, will
not science find some effectual means to rid us
of this unwholesome by-product, so that civil-
ization may eventually reach the goal which is
its aim?
DANGER AHEAD, IN THE CATHARTIC
HABIT
Hilton S. Read, M.D.,
Atlantic City. N. J.
Some 50 years ago a wise physician wrote
a little book entitled “Constipation, Plainly
Treated and Relieved Without the Use of
Drugs”. It was intended for circulation
among laymen and doctors, both. If it could
be published this year, without change, it
would be an acceptable modern treatise. So,
we have another evidence that there is really
nothing new under the sun. Ideas get shelved
and then, in time, come out in a new coat of
paint — but often still recognizable.
Half a century ago there were few mani-
curists, salesladies, barbers or shoe salesmen
who could not explain pimples, headaches,
dizziness, backache, cracking finger nails, and
a host of other complaints, by the word
acidity. Now — thanks to the newspapers and
magazines — most people are as familiar with
the picture of the colon as with the picture
of the Prince of Wales or of P>abe Ruth.
Even the radio is doing its bit to protect the
American colon, along with your Adam’s
apple. Now, instead of saying that you are
acid, your kindly, non-medical, volunteer ad-
viser would probably say that you are toxic.
And then the tragedy begins — if you believe
him and start self-treatment.
“He who treats himself has a fool for a
patient and a knave for a doctor.” Though
that is a questionable dictum, it is a fact that
pitfalls beset one on all sides when he at-
tempts self-treatment. The 2 greatest errors
the layman makes in self-diagnosis and self-
treatment are apparent ; the diagnosis may be
wrong, and the treatment may he wrong. A
simple, yet serious indictment.
Many who consider themselves so may
really not be constipated. When it exists, con-
stipation is inefficiency of a vital system. Its
treatment is just as important as the treatment
of diabetes, stomach ulcer, arthritis, or other
departure from health. It warrants the same
scientific study and treatment as the generally
accepted medical problems. Its causes are
legion, and its treatment often far at variance
from popularly accepted ideas. Just as it
would he laughable to be told that all people
between 40 and 50 years of age should wear
a size 6 B. shoe, so it is folly to think any
one treatment applicable to all types of consti-
pation.
Nature has been generous to us in having
endowed our bodies with many safety fac-
tors to protect us from our own indiscretions
and from accidents beyond our control. We
have in the human system much duplication
of function. If we, of necessity, lose a kid-
ney or an eye, or have a lung out of com-
mission, we can still live quite comfortably,
because a fellow organ will take on the added
responsibility. But. we have only one intestinal
system. Show it the same consideration you
show your automobile. Do not try to adjust
the carbureter unless you are a mechanic, and
then you had better have assistance of another
mechanic. The cathartic habit is dangerous.
Do not acquire it as the result of bad judg-
ment or advice.
August, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
661
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J.
Entered at the post office at Orange, N. J., as second-class matter
PUBLICATION COMMITTEE
HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J.
EDITOR:
HENRY O. REIK, M.D., P.A.C.S., Vermont Apartments, Atlantic City, N. J.
Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to
receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fact.
NOTE.— The transaction of business will be expedited, and prompt attention secured if:
All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to
The Editor, Dr. Henry O. Reik, Vermont Apartments, Atlantic City, N. J.
All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements,
or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication
Committee, (address above), Newark, N. J.
NECESSITY FOR VACATIONS
With the arrival of midsummer, no one re-
quires much urging to lay down the imple-
ments of his trade and take a vacation from
routine labors, for a rising thermometer slows
up other activities and the appeal of the
“great outdoors” is hard to resist. Even those
who have congenial occupations, who work
amid pleasant surroundings, and who really
love their work and dislike putting it aside,
should, however, if opportunity affords, take
advantage of any chance to secure a change
and develop the benefits of recreation. The
word recreation is defined as “refreshment of
body or mind”, and grows out of the verb
■ — re-create — meaning “to impart new vigor”
or to “refresh after labor”, and that implies a
necessity for replenishment of our natural
forces after an expenditure of energies.
One of our contemporaries, the Editor of
the Pennsylvania Medical Journal, some time
ago, in an editorial entitled “physiologic tides”,
drew an interesting picture of the ebb and
flow of living power, which picture is deserv-
ing of reproduction here :
“The comparison of an undulatory swing in
the higher things in life to the tidal move-
ments of the ocean has often been made in
prose and poetry, but the highest development
in all things, whether mental or physical, is
attained through such change and variation;
the sleeping hours are as necessary as the wak-
ing hours, rest as exercise, constructive as de-
structive metabolism. It would be well if this
truth were more generally and thoroughly ap-
preciated. •
What is it that is causing the nervous
breakdowns among our business men, society
women, and students? Does not every one in
this modern rushing life feel that there is
more put upon him than he can possibly do ;
more work and play and engagements and
cares? Yet, the trouble in most cases is not
that people are over-worked but that they
work against physiologic law. The business
man feels that there can be no pause in work
if he is to win success, and it is the con-
tinuity of strain that is killing him; the scholar
who studies night and day loses originality
and insight and finds himself becoming a
book-worm and a pedant. It is the old story
of ‘All work and no play makes Jack a dull
boy’, which might well be reversed to fit the
suffering from nervous exhaustion of plea-
sure-seekers whose lives are blighted by ennui
and discontent. The best work of our lives
is not done with the feverish, over-whelmed,
and burdened mind which comes from con-
tinuous, unvarying strain, whether physical or
mental, whether from business or pleasure.
We all need the ebb-tides of reaction, relaxa-
tion, and quiet thought in order that there may
follow the flood-tides of health and strength
for the real decisive efforts of life.”
THE OFFICIAL TRANSACTIONS
This year we are publishing the complete
Official Transactions, of the 165th Annual
Meeting of the Medical Society of New Jer-
sey, as a Supplement to the August Journal,
a month earlier than usual, and we strongly
recommend to all members a careful reading
662
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 19 31
of the reports submitted by officers and com-
mittees showing the accomplishments of the
organization and, especially, the progress
made during the past year. We believe you
will be gratified by the detailed accounts of
work performed and the promises of further
advancement to come from plans outlined for
the next fiscal year. Members who could not
attend the Asbury Park meeting will find in-
teresting reading in the full record of pro-
ceedings and will thus become conversant with
all that transpired during the convention, as
well as with the reports presented and action
taken with regard to plans for the future.
Those who did attend the convention will also
probably benefit hv reading the transactions,
through the fact that it is difficult to follow
closely and understandingly the public presen-
tation of a report; whereas, the subject matter
is easily understood and absorbed when read
in the quiet atmosphere of the office or home.
In the July Journal we mentioned the un-
usually large number of special committees
for which provision was made at Asbury Park,
and referred to that fact as indicating increas-
ing interest in some of the problems, par-
ticularly economic problems, now confronting
the prbfession. President Hagerty has prompt-
ly appointed most of those newly provided
for committees, and has requested all ap-
pointees to respond at once — expressing will-
ingness to serve — or else to decline and make
way for the appointment of others who can
and will work.
On the last page of the advertising section
of this Journal we present a revised list of the
officers and standing committees for this fiscal
year. Some of the special committees will be
mentioned editorially so that other mem-
bers desiring to submit information or sugges-
tions bearing upon special problems under
consideration will know with Whom to com-
municate.
STUDY OF STATE MEDICINE
Among important special committees, pro-
vided for at the recent convention, is one in-
structed to study the question of so-called
state medicine. This topic was presented in
one form or another by the President, the
Secretary, the Executive Secretary, and other
officers and members in the course of deliver-
ing committee reports or in discussion. At the
present moment, no other single topic is re-
ceiving so nearly universal consideration bv
members of the medical profession. We have
stated before that in the brief course of 5
months, May to October, in 1930, this office
collected from one source alone — other state
society journals — 28 articles, dealing especially
with the possible or probable advent, into the
United States, of state medicine as it appears
in “national health insurance laws” of other
countries. We can now say that an additional
group of 35 articles has been abstracted from
the same source during the past 9 months.
These 63 papers do not by a long way repre-
sent the total output of literary contributions
to the subject; though they do fairly well rep-
resent the arguments’ for and against this
“socialistic" — or, as some writers describe it,
“evolutionary” — proposition.
We have learned, without surprise, that the
Secretary, Dr. Morrison, and the Editor, have
been accused of favoring adoption of state
medicine. No charge could he much further
removed from the truth. Both of us knew in
advance of our speaking or writing upon the
subject that some listeners or readers would
probably misunderstand or misinterpret our
motives, but an honest man cannot side-step
duty merely to escape criticism or false ac-
cusations. We explained on various occasions
that we felt impelled to direct the attention of
members to this matter, offering what factual
information was to us available, in order that
the physicians of this state, at least, might
become familiar with the subject and pro-
tect themselves against such legislation as has
elsewhere worked to the detriment of the pro-
fession and of the people. “In knowledge there
is strength!” If that axiomatic statement he
true, let us gather in all possible knowledge
concerning this matter, for we will need the
strength.
The special committee appointed to invest-
gate and study the question consists of Drs.
Francis FI. Todd, Chairman; Efenry C. Bark-
horn, W. Blair Stewart, John H. Rowland
and Barclay S. Fuhrmann.
August, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
66 3
Medical Ethics
THE LAW IS AN ASS
(From The Kalends, Williams and Wilkins
Company. )
There is no originality attached to the above
caption for, as is generally well known, it first
was used upon a memorable occasion by the
beadle, Mr. Bumble, in Oliver Twist. But even
the despicable Mr. Bumble did but give voice
to a thought often found lurking in the minds
of thinking men throughout all the ages of
which there are tangible records. Let us go
back to the territory presumably immediately
adjacent to the Garden of Eden. Did not Cain
seek to dodge the issue when he countered the
leading question by naively inquiring : Am I
my brother’s keeper? According to Scripture,
Cain knew jolly well what had happened to
Abel.
The example of Cain is not cited as an ex-
tenuation of regarding the law as an ass, but
simply as an illustration of how an issue may
be avoided by asking pettifogging questions
seemingly relevant but misleading. Even to-
day, thousands of years since the time of Cain,
most people are more concerned about the
merits or demerits of Cain’s question than
they are as to the point originally at issue,
viz., did or did not Cain slay Abel, and if he
did so was he justified in doing it? Perhaps
he was. Who knows? But certainly there aiJe
numbers of people today who invoke the aid
of the law in an outrageous manner to enable
them to answer in the affirmative Cain’s dodg-
ing question of Am I my brother’s keeper?
Especially is this true in so far as their
“brother’s” morals are concerned. And the
law aids such self-appointed custodians of
morality. Why? The only intelligent answer
deducible is that the law is an ass.
Is it not true that for more than a century
our national government wisely steered clear
of legal interference with personal habits?
Such matters were sanely left to the jurisdic-
tion of states and municipalities. A, bout 20
years ago, however, due to the agitation of
paid doers-of-good, the national government
jumped into the puddle with both feet. With
what result is well known to students of gov-
ernment and politics, medical men, and scien-
tifically trained sociologists. The mere opin-
ions of paid doers-of-good can have no weight
when placed in the balance with the results of
scientific research.
The Harrison Act upon narcotics, the Mann
Act upon prostitution, and the Volstead Act
prove conclusively that our national law is an
ass. Scripture tells us that by their fruit ye
shall know them. The fruits of the ungodly
trinity above mentioned are : Before the pas-
sage of the Harrison Act there were 100,000
drug addicts in the United States, today there
are more than 2.000,000; the Mann Act was
to. “cure” a relatively minor and local evil, to-
day sexual license is rampant throughout all
strata of society; the Volstead Act was to so
function that all jails would be emptied, crime
diminished, and all homes made happy, today
President Hoover authorizes the expenditure
of $6,500,000 for national penal institutions,
because those of all states and municipalities
are filled to overflowing, he also has appoint-
ed a committee of outstanding citizens to in-
vestigate and report upon the magnitude of
our national crime record, and if the output
of our legal divorce mills is a criterion upon
happy homes, then Mr. Volstead did but add
oil to the flames.
All these pernicious results of the assininity
of our national law are as naught when con-
trasted with the damage done to clear and
straight thinking, for the essential self-dis-
cipline of body and soul has been replaced by
the silly doctrine that a majority in the ballot
box is the arbiter of right and wrong, and —
law. It is easy to figure out why it so often:
happens that the law is an ass.
Esthetics
TIMES SQUARE HAS A SUMMER
VISITOR
(From New York Times, July 3, 1931.)
Glimpsed, in Times Square, a butterfly.
Not a metaphoric butterfly, but a real one, all
brown and beautiful, and very gay and lively,
in spite of his long trip from somewhere.
Perhaps from Central Park, or across the
river.
If he had been just a figure of speech a
moth would, of course, have been more appro-
priate— to the night lights, at any rate. But
this visitor was an actual creature, and he
came in broad daylight. What attracted him?
Maybe the cool morning breeze wafted him
on his whimsical way. Maybe he smelled a
rotten banana, on which even the best nur-
tured butterflies dote.
He flitted past the sign in a restaurant win-
dow advertising half a cold lobster with cold
slaw and potato salad for 60 cents, without
so much as batting a wing. Overhead a gar-
ish sign advertised the Return of Dr. Fit
Manchu. but he was absorbed in deeper mys-
teries. He did not stop to read even “The
Green Pastures” ad, although it might have
allured him. Instead, he perched, this early
morning voyager, a little weary but content,
on the roof of a Coney Island bus.
664
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 19 31
Collateral Reading
THE IMMORTAL LYDIA
The above title of a recently published
book naturally attracted our attention, because
of interest in the general subjects of patent
medicines and effective advertising to the gul-
lible public. Once upon a time we clerked in
a country drug store, and, though it was
many years ago, we still remember the buying
demand for Lydia Pinkham’s Compound. We
have not had time to make a personal review
of this biography — The Life and Times of
Lydia Pinkham, by Robert C. Washburn —
but inasmuch as the Saturday Review of
Literature, of May 30. 1031, has published a
very interesting summation of the book’s con-
tents, we are taking the liberty of passing
that along for the entertainment and edifica-
tion of our readers :
“Reach for a vegetable instead of a sweet.”
This prophetic phrase appeared in the ad-
vertising of Lydia E. Pinkham’s Vegetable
Compound in 1891. It was a part of the skil-
ful publicity campaign which, in the course
of 50 years, converted a harmless nostrum,
prepared by a farmer’s wife over a kitchen
stove, into the greatest of all patent medicines.
Lydia Pinkham, dead since 1883, still smiles
benevolently upon the world, offers her pri-
vate advice to thousands of feeble-minded fe-
males, and sells several million dollars worth
of her preparation every year.
The engaging story of this gigantic hoax
is told by Mr. Washburn with an abundance,
even a superabundance, of detail. Lydia Estes
Pinkham was not only a real person but a
personable person. Born in Lynn, Mass., on
February 9, 1819, she was brought up as a
Quaker and became in her youth a militant
abolitionist and feminist. After she gave up
school-teaching to marry Isaac Pinkham, her
life was devoted for the next few years to
child-bearing, while her husband tried eveiw-
thing from business to farming. Eventually,
he plunged heavily into real estate and was
broken in the financial crash of 1873. It was
then that Mrs. Pinkham came to the rescue
with her Vegetable Compound, an elixir of
herbs and alcohol, prepared according to a
formula originally received by her husband
in cancellation of a bad debt. Hitherto she had
occasionally cooked up the mixture for her
familv and friends in time of illness. It was
now to prove equally useful in time of pov-
erty. One of her children suggesting that
they put the Compound on the market, all of
the family rallied to the support of the idea.
The next 5 years were spent by the mother in
brewing and stewing, by the 3 sons in peddling
bottles and circulars from Boston to New
York. The extracts from their correspon-
dence given by Mr. Washburn are delightful.
The Compound was advertised to cure “wo-
men’s weakness”, but young Dan Pinkham
reported that, while men eagerly read the cir-
culars, women tore them up if the}- saw any-
one looking. He suggested, thoughtfully,
that it would be well to mention a few men’s
diseases. His mother was nothing loth, being
certain that her Compound would cure any-
thing and everything. She continued to ap-
peal mainly to women, however, and grad-
ually came to regard herself as the savior
of her sex. Recognition of this role was
achieved in 1880 with the publication of her
picture. The confidence created by so
matronly and respectable a countenance was
overwhelming. The sales of the Compound
went bounding up, and the flood of personal
letters began. Mrs. Pinkham answered these
herself at first ; then she trained her daughter
and daughter-in-law to help her; finally women
clerks were employed whom, however, she
taught with equal care. She was most in-
sistent that feminine delicacy should always
lie respected. The word “leg” must never be
mentioned. Her modesty preferred to write,
for example, that a patient had “a purple place
nearly as large as her hand . . . about 8
inches above her knee on the inside of her
right limb”.
The Compound made the family fortunes
but it did so too late to benefit greatly the
original producers. Two of Mrs. Pinkham’s
sons had literally worked themselves to death
in its behalf. Dan dying at 33 and Will at 28.
Mrs. Pinkham herself lived for only 3 years
after her success. Her heirs made a genuine
effort to acknowledge her decease and, tact-
fully, to substitute her daughter as a second
savior of the sex. But the world of women
would have none of this. They insisted upon
having their own Lydia. So the firm revived
the old lady and mounted upon her posthu-
mous wings to greater glory. Every attack
upon the Compound merely increased its sales.
Edward Bok's denunciation in the Ladies'
Home Journal sent them soaring. Though
the Food and Drug Act has shorn the plum-
age from the advertising until today the Com-
pound is recommended, with unquestionable
truth, merely “as a vegetable tonic in condi-
tions for which this preparation is adapted",
nevertheless the immortal physiognomy of
Lydia Pinkham still goes marching on.
Mr. Washburn rightly emphasizes the sig-
nificance of his heroine as one of the found-
ers of modern personal advertising and as a
contributor to the present reign of feminism.
But he is too over-awed by the magnificence
August, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
665
of her achievement to do full justice to the
essential comedy of her story. He wastes
much space in apologia — which is much as if
one should apologize for Falstaff or Bottom
the weaver. There is a good deal of padding
in the book. Thus a whole chapter — and a
very uniiluminating one — is devoted to Mrs.
Eddy, simply on the grounds that she. too, dis-
believed in doctors, was a self-advertiser and
a feminist, and lived in the same town with
Mrs. Pinkham. The endeavor to trail a whole
period from Lydia’s skirts is unsuccessful. To
take her quite so seriously is to wrong the
dear woman.
In Lighter Vein
Cross Marks the Spot
A man touring Europe sent back a picture post-
card bearing 'the message :
“Dear Son:
On the other side you will see a picture of the
.rock from which the Spartans used to throw
their defective children. Wish you were here. —
Your Dad.’’ — Wall Street Journal.
Change of Diet
It was the duty of Janet, the maid, to tie up
Jeff, the house dog, every night before she re-
tired. One night she failed in her duty, and next
morning found Jeff loose.
He had played havoc with the contents of the
larder. When the mistress heard the news, she
inquired :
“Has he eaten much, Janet?”
“Every blessed thing”, replied the maid, “ex-
cept the clog biscuits!” — Tit-Bits.
Voice of the Tempter
Small Boy: “I don’t think the gentleman next
door knows much about music.”
Mother: “Why?”
“Well, he told me this morning to cut my drum
open and see what was inside it.” — Birmingham
Gazette.
Whiskers on It
'Comic Artist: “This joke ought to be good, I’ve
had it in my head for 10 years.”
Heartless Editor: “Sort of aged in the wood, as
it were.” — Hummel.
Oh, My!
Parent (anxiously) : Nurse, is it a him or a
her?
Nurse: It's a them. — Boston Transcript.
Selfish Man
Bluebeard: You have the freedom of the entire
house excepting this closet. This, you must never
enter.
His Eighth Wife: Do you mean to keep an entire
closet for yourself when I haven’t room to hang
half my things.
Lighthouse Observations
ACUTE HEMORRHAGE FROM CORPUS
LUTEUM AND GRAAFIAN FOLLICLE
In 1917, Novak reported that a search of medi-
cal literature disclosed only 40 recorded instances
of copious hemorrhage into the abdomen caused
by ruptured Graafian follicle or corpus luteum.
During the 13 years since that announcement, 37
additional cases have been discovered, including
the case related by V. Earl Johnson, who reports
the most recent search of literature (Am. Jour.
Surg., 9:538, September 1930), bringing the pres-
ent total up to 77. In describing his own case,
Johnson discusses the etiology of this unusual
condition and some of the difficulties in making a
differential diagnosis.
After explaining the physiology of ovulation,
he says: “It is easy to imagine injury or a solution
of continuity of these fragile vessels brought on
by a sudden hyperemia of the pelvic organs, as by
sexual excitement, or by a sudden increase in the
intravascular pressure due to sexual excitement
or increased intraabdominal pressure. After in-
jury to these vessels a hematoma forms in the
corpus luteum cavity and if hemorrhage persists
long enough the pressure in that cavity will be-
come so great as to burst the wall at its weakest
point. It has been proved that a large proportion
(60 to 80%) of all ovaries removed at operation
show hematoma formation in some part of their
structure, showing the vulnerability of the smaller
ovarian vessels. This bursting of the walls of
the corpus luteum might eventuate in a copious
hemorrhage or in a trivial one. This seems to me
the theory most likely. Whether there is a
pathologic condition of the ovarian (or more
strictly, thecal) vessels, as shown by Schumann
to be present in his case, remains unsettled. Ref-
erence to the pathologic study in my case is in-
cluded in this paper. The pathologic changes in
the vessels in Schumann’s case is a very interest-
ing observation, but whether there was any re-
lation between such pathology and the hemor-
rhage is debatable. The question of cause and
effect is not thereby demonstrated, for there is no
reason why the hemorrhage could not have been
a coincident condition. I do not believe that
changes in the vessels alone would satisfactorily
explain the occurrence of hemorrhage.
Returning to the normal physiology of the
ripening Graafian follicle, we note that hemor-
rhage occurs into the cavity after the ovum has
been expelled. This hemorrhage occurs from the
thecal vessels. The additional physiologic hemor-
rhage from laceration through the stigma is no
doubt negligible because the point of rupture has
become so thinned out by pressure of the develop-
ing follicle. A pressure ischemia of an oblitera-
tive nature would seem most logical in the pro-
duction of the stigma. Presuming that in the
ovary a Graafian follicle is almost, but not en-
tirely, ripe when a sudden hyperemia of the pelvic
organs occurs and causes an increased intravas-
cular pressure in the ovarian blood vessels, pre-
mature separation of the ovum within the follicle
might occur. This premature separation would
produce hemorrhage into the follicle and if this
hemorrhage was continued sufficiently long a
bursting of the follicle at its weakest point would
naturally occur. Intraperitoneal hemorrhage
would then take place from the thecal vessels and
from the laceration in the ovary. This hemor-
666
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
rhage might be copious or trivial. I believe that
in all the cases presenting serious hemorrhage such
a process occurs in Graafian follicles that are not
quite ready to rupture. In other words, a prema-
ture separation of the ovum, with hemorrhage,
and premature rupture of the follicle, are the
mechanisms producing the condition under dis-
cussion.
It is very significant that in the 25 case reports,
used as a basis of study for this paper, increased
intraabdominal pressure was specifically mention-
ed in 9 cases. Eight of those patients stated that
intraabdominal pressure was increased either by
vomiting or by straining at stools. In view of the
frequent diagnosis of appendicitis in these cases,
and realizing that the majority of appendicitis
cases vomit one or more times, I am satisfied that
the incidence of increased intraabdominal jjressure
would be greatly increased if definite records of
this point had been made in all cases. It is in-
teresting, however, that it was definitely stated in
approximately one-third of the cases studied.
What is the possibility of making a correct
diagnosis before operation? This study has found
77 cases reported with a diagnostic error of exactly
100%: no case having been diagnosed correctly
previous to operation.
The greater number of mistakes have been
made in diagnosing the condition as acute appen-
dicitis, because of the pain in the right lower
quadrant, vomiting, fever and leukocytosis. It
therefore appears that the physical examination
must be the all important factor. The chief differ-
ences in favor of hemorrhage from the ovary
would be: (1) Pallor of skin and mucous mem-
branes: (2) more shock: (3) fainting or sinking
spells; (4) less amount of rigidity of rectus which,
in fact, may be absent; (5) area of exquisite ten-
derness is rather definite in appendicitis, while
with ovarian hemorrhage the tenderness is rather
diffuse over the lower quadrants.
Differentiation from ruptured ectopic pregnancy
is more difficult. They both have in common: (1)
Cramp-like pains over one or the other lower
quadrant; (2) fainting or sinking spells; (3) evi-
dence of internal bleeding- (4) fever and pulse
elevation; (5) leukocytosis.
Ruptured ectopic pregnancy usually gives a his-
tory of one or more abnormal menstrual periods,
there is usually some vaginal bleeding, softening
of the uterus just proximal to the internal os
may be present, and the breasts may show the
changes of early pregnancy. If there is bleeding,
not menstrual in type, from the uterus, the case
is probably not one of ovarian hemorrhage. This
vaginal bleeding was present in only 1 of the 25
cases studied.
However, it is much easier to make the diag-
nosis on paper than it is in practice and, without
practical experience to keep this possibility in
mind, past records suggest that the condition will
be confused with the 2 commoner ones, appen-
dicitis and ectopic pregnancy. The diagnosis should
not be missed by those who have previously en-
countered the condition."
Mental Hygiene and the Child
(During the past year our Field Secretary has
been using mental hygiene as the principal theme
in her public educational work, lecturing to large
groups of school teachers and pupils especially,
and the following editorial from the Pennsylvania
Medical Journal of March, 1931, seems appropriate
for repetition here) :
‘‘Possibly no other contribution to the study of
the child’s conduct and behavior has aroused the
interest of the general practitioner as has men-
tal hygiene. It is true pediatricians have always
considered the mental, nervous, and physical re-
actions of children, but, in the field of general
medicine, the psychologic aspect of the child, like
consideration of the psychologic aspect of the
adult, somehow or other in the passing years re-
ceived minor consideration.
In arousing this interest, the true mental hy-
giene workers have tried in every way possible
not to infringe on the territory of the pediatri-
cian; per contra, they have always been conscious
of the pediatrician’s cooperation and his contribu-
tion to the knowledge of the child. Their efforts,
therefore, have been more along the lines of re-
minding the general practitioner, the parents, the
teacher, the nurse, the social worker and society,
that childhood is the golden period for proper
guidance of the growing child: that it is here the
child should be given the best opportunity for de-
velopment of his psychologic processes which will
enable him to meet, life’s situations, and encour-
agement in developing proper adaptation and men-
tal attitudes.
To this end. mental hygiene sponsored the men-
tal clinics in the field either as independent units
or part of our governmental agencies and the
mental hospitals. Child guidance clinics were also
sponsored for the further research, study, and
guidance of certain types of children, all of which
was for the purpose of making available places of
examination of children of all ages who are not
able to effect adaptation to the new world in which
they find themselves.
Time has proved that mental hygiene made no
error in focusing on the child as one of its first
steps in the broad program of the promotion of
mental health and the prevention of mental dis-
ease. The case records of these clinics reflect in
numbers and types of children examined, that such
agencies are meeting a very definite need. The
physician in general practice will make no mis-
take in availing himself of the facilities of these
clinics in many of his cases of problem children
when consultation is desired.”
Current Events
THE 82nd ANNUAL/ CONVENTION OF THE
AMERICAN MEDICAL ASSOCIATIOtN
Following close upon our own State Society’s
16 5th Annual Meeting, and convening at a place
so convenient for most of our members, the Phifa-
delphia session of the American Medical Asso-
ciation attracted a large attendance from New
Jersey. Our registration figures (565) being sur-
passed by only 2 states- — Pennsylvania (2806) and
New York (936). As the total number of regis-
trants was 7006, New Jersey supplied 8% there-
of.
New Orleans was chosen as the place for meet-
ing next year.
Dr. E. H. Cary, of Dallas, Texas, was unani-
mously chosen as President-Elect.
From the general proceedings we have selected
the following items as being of special interest
to New Jersey physicians.
Dr. E. Starr Judd, President-Elect to succeed
President William Gerry Morgan, addressing the
House of Delegates, said, in part:
An association is as strong as its man power.
August, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
667
Few associations that I know of have as many
capable and industrious officers and departmental
heads as has the American Medical Association.
This condition must be maintained. If, for any
reason, a new man is needed to fill in and super-
vise a new bureau or to replace some one, the
best person available must be obtained. In the
selection of men for bureaus and committees there
will constantly be competition with large organ-
izations and foundations and the various medical
centers. These foundations have much money to
spend for personnel, and for this reason, if the
Association is to continue to have the best, as
it must have, it must expect not only to pay well
but also to see that each and every one of the
permanent men on these bureaus and committees
is well cared for in every way. A strong financial
foundation is necessary for the success of any or-
ganization and in order that our position may be
maintained we must make every effort to increase
our resources and to establish funds for stability
and future development.
Much has been said about a new building for
the headquarters of the Association, and all are
looking forward to the time when this plan can
be carried out. I know that the trustees have
given careful thought to plans for a new building,
and any help that might be offered, I am sure,
would be welcome. I understand that a building
fund has already been started, but it does not seem
to me that it would be good business to postpone
the building of the contemplated structure until
we have money enough to pay for it. It seems
to me that it would be a fine thing if the medical
profession itself could finance the structure. First
of all, a new building would be a great source
of pride and satisfaction, as well as most stimu-
lating.
A new building would give an opportunity for
more and better space, for the development of
our already large and active library. It takes
many years to build up a library, and anything
that facilitates this must be considered.
A room containing portraits of leaders in
American medicine as well as those of leaders of
medicine in other countries, and historical data
concerning those who have accomplished much
in medicine, will be most stimulating and appro-
priate in this buildng.
The new building should contain a small audi-
torium and several committee rooms of good size,
some of which could be used as permanent quar-
ters of the different councils.
Bureau of Health and Public Instruction
The Bureau of Health and Public Instruction
has ever-increasing duties and associations. The
American Medical Association must be the leader
in preventive medicine and public instruction and
in public health activities. Public health and pre-
ventive medicine are the most discussed subjects
in medicine today, and influence and leadership
in this work must be retained.
Those who attended the meetings of the White
House Conference must have been impressed with
the fact that so few physicians were present.
While the profession welcomes cooperation from
the outside organizations, nevertheless it is of
interest to society and of importance to medicine
for us to retain our position in these affairs.
A great deal of very commendable work has
been done on public health, preventive medicine,
public instruction, child welfare and all other
phases of this subject by this bureau and also by
certain state organizations. This is especially
evident in Illinois, New York and several other
states. I make a plea that we not only continue
our efforts but that we enlarge them and main-
tain our position.
Bureau of Medical Economics
The Bureau of Medical Economics is just being
organized and ultimately will have all available in-
formation regarding the cost of medical care. So
much misinformation regarding economics is
being broadcast that it is certainly our obligation
and responsibility to set this aright. This means
a great deal of study and work, and is a task for
those who have had much experience in these
activities. There are few actual practitioners of
medicine on the 5-year committee on the costs of
medical care. The statistical work of the com-
mittee has been tremendous, and a great deal of
information will be available. It seems to me
that a bureau made up of men from the Asso-
ciation would be better able to put the proper in-
terpretation on the findings of this committee
than would those in government and public
health work alone. This bureau must have the
best man power that can be obtained.
Resolutions on Appointment of a Commission on
Qualifications for Specialists
Dr. Carl F. Moll, Michigan, presented the fol-
lowing resolutions which were referred to the
Reference Committee on Medical Education:
Whereas, The advancement of medical
science through the results of research and
practical experience has stimulated many
physicians to confine their professional ac-
tivities to limited and special fields of medi-
cal practice, and
Whereas, There has thus been created
class of specialists in medicine, and
Whereas, There appears to be a growing
tendency on the part of physicians who are
not properly qualified to hold themselves out
as specialists; therefore be it
Resolved, That the Speaker of the House
of Delegates shall appoint, by and with the
advice of the President and the Board of
Trustees, a Commission on Qualifications for
Specialists, composed of 9 members; that
said commission shall undertake to define the
qualifications that should be required of the
individual physician who desires to limit his
practice to any special field and to be known
as a specialist, and that in arriving at such
definition the Commission on Qualifications
for Specialists should give 'consideration to
questions of education, training and clinical
experience; and be it further
Resolved, That this commission shall give
consideration to the present status of special-
ization in medicine, and shall define the var-
ious specialties which in the opinion of the
commission may be considered as necessary
for the best interests of the public and of
scientific medicine; and be it further
Resolved, That the Council on Medical Elu-
cation and Hospitals be directed to render
its assistance to the Commission on Qualifica-
tions for Specialists, and that the Board of
Trustees be requested to provide necessary
clerical assistance; and be it further
Resolved, That this commission shall report
to the House of Delegates concerning the ad-
visability of the possible enactment of legis-
lation whereby state boards of medical ex-
668
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1031
aminers or other bodies charged with the ad-
ministration of practice acts may be em-
powered to issue special licenses to physicians
who wish to qualify and practice as special-
ists; and be it further
Resolved, That the report of this com-
mission and its recommendations shall be sub-
mitted to the House of Delegates, through
its secretary, at the next annual session.
The Reference Committee on Medical Educa-
tion considered the above resolutions and pre-
sented the following report, which was unani-
mously adopted:
In regard to the resolutions introduced by Dr.
Carl F. Moll, Michigan, seeking definition of the
qualifications of those physicians who hold them-
selves out as specialists, and consideration of the
present status of specialization in medicine, your
reference committee is in entire sympathy with
the spirit of these resolutions, and after careful
study of them, and after thoughtful consideration
of reports presented to the committee by repre-
sentative otolaryngologists, ophthalmologists, der-
matologists and abdominal surgeons who appear-
ed before the committee, your committee recom-
mends that the Council on Medical Education and
Hospitals be requested to investigate the entire
subject and to make recommendations looking
to the establishment of proper qualifications of
physicians who shall engage in special practice,
and that the report of the Council and its recom-
mendations be submitted to the House of Dele-
gates as soon as practicable.
Resolutions on the Policy of Rendering Medical
and Hospital Benefits to Veterans with Non-
Service Connected Disabilities
Dr. H. H. Shoulders, Tennessee, presented the
following resolutions, which were referred to the
Reference Committee on Legislation and Public
Relations, and later adopted:
Whereas, The federal government has in-
augurated the policy of rendering medical
and hospital benefits to veterans of the World
War with non-service connected disabilities;
and
Whereas, This policy was inaugurated over
the opposition of the American Medical Asso-
ciation; and
Whereas, The policy now in force, if car-
ried to its logical conclusion, involves the
construction, the staffing, and the main-
tenance of a sufficient number of hospitals to
accommodate the hospital needs of all the
veterans of the World War; and
Whereas, Such a policy places the federal
government in unnecessary and unjust com-
petition with the civilian hospitals and the
medical profession of the United States; and
Whereas, The present policy is of unequal
benefit to veterans by reason of the fact that
many disabled veterans cannot (for one
reason or another) avail themselves of the
benefit; therefore be it
Resolved. That the House of Delegates of
the American Medical Association petition
the Congress of the United States and the
American Legion to abandon the policy of
rendering hospital and medical benefits to
veterans of the World War with non-service
connected disability, and substitute therefor
a plan of disability insurance benefits with
the following provisions:
First, the creation of a Bureau of Disability
Insurance in the Veterans' Bureaus as now
constituted.
Second, the issuance of a disability insur-
ance policy to each veteran with a disability
benefit clause, as follows:
(a) The payment of a weekly cash benefit
during a period of total disability, and
(b) The payment of liberal hospital benefit
sufficient to cover the hospital expenses of
a veteran during a period of hospitalization
for any disability. Such benefits to be paid
to a veteran on satisfactory proof of total
disability, and
(c) Such other provisions as are necessary
for the proper administration of the act.
Be it further
Resolved, That the proper officers of this
association be instructed to approach the offi-
cers of the American Legion with the view
to securing the adoption of the policy above
set out as a part of the legislative program
of the American Legion, and be it further
Resolved. That each state medical asso-
ciation be requested to form a committee
whose duty it will be to approach the state
and local Legion posts throughout the coun-
try with a view to securing the adoption of
this program by them.
Resolutions on Filling Out of Claim Proofs of
Health and Accident Insurance Companies
Dr. J. D. Brook, Michigan, presented the fol-
lowing resolutions, which were referred to the
Reference Committee on Miscellaneous Business,
and later to the Bureau of Medical Economics for
study and report at next annual meeting.
Whereas, The Michigan State Medical So-
ciety. through its Committee on Civic and In-
dustrial Relations, has made a comprehensive i
study of the question of filling out claim proofs
of health and accident insurance companies;
that this study has extended over a period of 3
years and has involved an extensive analysis of
the subject, including a conference with repre-
sentatives of several outstanding insurance
companies; and that, as a result of Such study
and conference, the Michigan State Medical
Society has adopted suitable resolutions pro-
viding for the charging of a fee to the in-
surance companies of not less than $2 for
filling out each preliminary and final claim
proof, and
Whereas, The Michigan State Medical So-
ciety, by its action in adopting such resolu-
tions, has created the interest and favor of
other state medical societies in the question,
which equally affects every other state medi-
cal society; and that the Michigan State
Medical Society has met with considerable
opposition from the insurance companies, for
the reason that they object strenuously to the
plan, and point out that Michigan represents
only a small section of the nation and should
not undertake a project affecting the policy of
all the insurance companies of the United
States, and
Whereas, The rights and privileges of the
individual physicians of the entire United
States are involved and are being encroached
on by the health and accident insurance com-
panies, which are continuing to insist that the
services of the physician in filling out claim
proofs are part of the physician’s professional
obligation to his patient: that the insurance
August, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
669
companies are unwilling to concede that the
information given to them is for their own
statistical use in properly adjusting claims;
and that they are unwilling to pay the physi-
cian his fees; therefore be it
Resolved, That the House of Delegates of
the American Medical Association concur
with and approve the action of the Michigan
State Medical Society in adopting resolutions
providing for the charging of a fee of not less
than $2 for each preliminary and final claim
proof; and that the House of Delegates of the
American Medical Association authorize its
Speaker to appoint a committee to whom
this problem shall be referred; and be it
further
Resolved, That this committee be instructed
to study the facts and factors involved and to
formulate a national policy that will result
in remunerating physicians and surgeons for
their service to insurance companies, when
rendering these reports that contain expert
opinions and professional advice; and be it
further
Resolved, That the committee of the Asso-
ciation shall make a full report and recom-
mendation at the next annual meeting of the
House of Delegates of the American Medical
Association.
Committee on Reports of Officers
The following notes are abstracted from this
committee’s report;
Your committee feels that the time has arrived
when the medical profession should direct all
independent or extragovernmental or lay health
groups.
We congratulate the association on the manner
in which its offices have been conducted during
the past year by its able and efficient manager
and Secretary, Dr. Olin West.
We approve of the expressed desire of the
Board of Trustees to acquire the land necessary
for erection of a new, larger and more adaptable
building to meet the growing demands of the
Association. In view of the present economic
conditions and the urgent needs of the Associa-
tion, we believe that now is the opportune time
to construct the new home.
We are gratified at the position attained by
The Journal as the leader of medical publications,
as well as the high standard of the special jour-
nals in their respective fields.
We appreciate the work being accomplished by
Hygeia, especially in schools, and we feel that
the Woman’s Auxiliary is largely responsible for
the rapidly increased circulation of Hygeia.
We approve of that part of the report of the
Trustees advocating the education of the public
on all matters pertaining to health and disease
through radio talks, properly supervised, lay mag-
azine articles and public lectures.
We especially commend the Bureau of Legal
Medicine and Legislation in reference to national
legislation in connection with the Jones bill (off-
spring of the Sheppard-Towner Maternity and In-
fancy Act), the narcotic legislation, the World
War Veterans’ legislation, the many bills intro-
duced intended to create federal subsidies, and
the government control of individual activities in
the several states.
We note with pride the increasing importance
of the annual Scientific Exhibit, and we recom-
mend that it be continued and expanded to the
highest possible degree.
We anticipate substantial contributions from
the newly created Bureau of Medical Economics.
The possible benefits to the profession from con-
structive activities in this bureau should prove
invaluable.
In reference to the care of the World War
Veterans, your committee suggests that the House
of Delegates go on record as being opposed un-
alterably to giving free medical and surgical care
to those suffering from injury or disease of non-
service origin.
Further Report of Reference Committee on Re-
ports of Board of Trustees and Secretary
Dr. C. .T. Whalen, Chairman, presented the fol-
lowing report:
At the morning session, that portion of the re-
port of the committee having to do with the
Secretary’s report, which read as follows, was re-
ferred back to the committee for further con-
sideration:
We especially condemn the examination of
pre-school children en masse in clinics, health
units and similar agencies. Such examina-
tions cannot be but perfunctory, superficial
and unsatisfactory to p'hysicians and child
alike.
The committee submits the following amend-
ment:
We , commend education of the public as to
the necessity for medical supervision of the
pre-school child by the family physician, and
we insist that medical examination of each
child should be thorough and individual.
Dr. Whalen moved the adoption of the amend-
ment. The motion was seconded by Dr. John O.
Polak, Section on Obstetrics, Gynecology and Ab-
dominal Surgery, and carried.
Executive Session
Two sets of resolutions under consideration
were somewhat modified, and are presented here
as finally acted upon:
(1) The committee has ascertained that the
intent of this resolution is to urge on the mem-
bership of the American Medical Association the
importance of initiating in county and state so-
cieties and in the House of Delegates of this As-
sociation resolutions on questions of medical eco-
nomics and social relations, rather than in special
societies of limited membership with a view to
presenting to the public opinion of organized
medicine as a unit and to prevent the presenta-
tion of a divided opinion before legislators and
the public in general.
In order to express this more fully and more
definitely, the committee has rephrased the reso-
lution and now offers it for your consideration
in the following form:
Whereas, The American Medical Associa-
tion, through its county and state organiza-
tions and through its House of Delegates,
affords to each of its members representation
whereby he may express his views, and, if
approved, receive the support of organized
medicine; and
Whereas, The American Medical Associa-
tion is the largest body of physicians in the
United States, representing every specialty,
democratically organized, and including more
than 100,000 physicians; and
670
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 10 31
Whereas, From time to time, members of
the American Medical Association, holding
membership in various medical societies, or-
ganized for scientific advancement, have initi-
ated in such bodies resolutions defining medi-
cal policies and opinions on questions of
medical economics and social relations; and
Whereas, Resolutions on such subjects
adopted by such organizations are given wide
publicity as representing the views of the
American medical profession, notwithstand-
ing the fact that such bodies are of limited
membership and specialistic interest; there-
fore be it
Resolved, That the House of Delegates of
the American Medical Association urge all
members of the Association to initiate such
resolutions in their county or state societies
or in the House of Delegates of the Ameri-
can Medical Association, and that an effort
be made, through the periodicals of the Asso-
ciation, to inform the membership, and also
all organs of public expression, that the
American Medical Association is the one
body, in organized medicine, entitled to speak
for the vast majority of the physicians of this
county.
The above resolution was adopted.
(2) Resolutions referred to the committee were
presented by Dr. Roland Hammond, Rhode Island.
These resolutions read as follows:
Whereas, The Congress has undertaken to
fix the doses of wine and whisky and brandy
by legislative fiat, thus taking over the func-
tions of pharmacologist and physician; and
Whereas, The Volstead Act compels physi-
cians to betray the confidence of their pa-
tients by keeping a record of their diseases
and ailments for inspection by federal prohi-
bition agents, thus violating the traditions of
the medical profession, medical ethics and the
laws of a number of states; and
Whereas, Relief from these conditions has
been sought in the courts and has been denied
by the United States Supreme Court; and
Whereas, The Wickersham Commission has
unanimously made the recommendations:
“Removal of the causes of irritation and
resentment on the part of the medical pro-
fession by: (a) doing away with the statu-
tory fixing of the amount which may be pre-
scribed and the number of prescriptions; (b)
abolition of the requirement of specifying the
ailment for which liquor is prescribed on a
blank to go into the public files; (c) leaving
as much as possible to regulations rather than
fixing details by statute.’’ Now, therefore, be
it
Resolved, That the Rhode Island Medical
Society hereby urges each of its members to
demand of his senators and congressmen the
repeal of those portions of the Volstead Act
which substitute the fiat of Congress for the
seasoned opinion of the medical profession,
which rob the sick of their right to be heal-
ed of their diseases and ailments according
to the recommendations of eminent medical
authorities, and which deprive the physician
of his right to the free exercise of his judg-
ment in the practice of his profession; and
be it further
Resolved , That the delegate of the Rhode
Island Medical Society to the American Medi-
cal Association be, and hereby is, instructed
to present this resolution to the House of
Delegates of the American Medical Associa-
tion at its next meeting for similar action.
Dr. Taylor read the following endorsement of
the Pteference Committee on the Reports of Board
of Trustees and Secretary, presented at the Wash-
ington session in 1927:
Your committee would therefore recom-
mend that with the cooperation of the special
committee headed by Dr. Mayer, of Pennsyl-
vania, and the excellent executive of the
Bureau of Legal Medicine and Legislation,
Dr. Woodward, the Board of Trustees be di-
rected to prepare a bill to be presented to
Congress correcting the unfortunate pro-
visions of the Volstead Act limiting the
amount of alcohol used, and providing such
regulations as will permit doctors to pre-
scribe whatever amounts of alcoholic liquors
may be needed for their respective patients,
and subject to such reasonable restrictions
as may be thought wise and best after a con-
ference with the head of the prohibition de-
partment.
Dr. Taylor moved the adoption of the above.
The motion was seconded by Dr. A. J. Bedell,
New York, and carried.
Communication from President of the
Woman’s Auxiliary
The Secretary read the following communica-
tion from Mrs. J. Newton Hunsberger, President
of the Woman's Auxiliary:
To the Members of the House of Delegates:
It has been my privilege for the past year to
serve the Auxiliary to the American Medical As-
sociation as President. During that time we have
endeavored to bring to a greater stage of perfec-
tion our organization rather than to enlarge our
membership, which, however, has ably taken care
of its own progress as we have now 13,000 paid
members in 3 7 states (organized).
We have installed a new system of recording our
membership which will enable states as well as
counties to keep a systematic and correct file.
A tabulation of the 37 replies received to the
37 questionnaires sent out shows two thirds of the
states have, now, advisory committees in their
respective medical societies. Fourteen states have
definite study outlines prepared for their use by
the state medical society or their boards of pub-
lic health. Most auxiliaries contribute to and
read their state medical journals. All have par-
ticipated in local, social programs and at state
medical conventions, and so have increased socia-
bility in the profession.
One new study has been prepared and dis-
tributed by the Program Committee and is being
extensively used not only by our own members
but also by the parent-teachers associations and
the woman’s clubs. The subject is “Communic-
able Disease Control” arranged in 4 parts: In-
troduction, Small-pox, Diphtheria, Typhoid
Fever. To date 3500 copies have been dis-
tributed.
Our Public Relations Committee has made con-
tacts which enable us to work through.
The Chairman of Hygeia divided the states into
5 districts with a supervising chairman over each.
Letters were mailed to all state presidents seek-
ing their cooperation. Replies received from 32
August, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
671
states resulted in securing- the names and ad-
dresses and terms of office of about 35 0 county-
presidents and Hygeia chairmen. A survey of
the reports shows that a majority of the aux-
iliaries are extolling the merits of Hygeia for its
educational value but it is very difficult to com-
pete with other good magazines at the present
price.
Cur women take much interest in working for
scholarship and medical benevolence funds. They
rendered great assistance during the drought
disaster, individually and through the Red Cross.
They have participated in May Day Child Health
programs, Christmas celebrations and summer
outings for children in hospitals. They have
housecleaned medical libraries to the satisfaction
of critical doctors.
Some legislative work has been done in states
but only under the direction of the advisory com-
mittees.
A large number of our auxiliaries take special
delight in collecting historical material incident
to medicine and the doctor of the past.
Turn about is fair play but we do greatly ap-
preciate the courtesy of the American Medical
Association through Dr. Olin West in printing
the minutes and reports of our Detroit session
and also for the use of 2 pages in the Bulletin
for the broadcasting of auxiliary news to our
members, a much needed medium. The one re-
gret is that all husbands are not Fellows, so fre-
quently the Bulletin does not And its way to our
members. What is the solution of this problem?
We have visited 12 different states during the
year and we feel the contact personally was not
only enjoyable to us but beneficial to our mem-
bers.
Two thousand pieces of mail have been sent
from this office and many more by the chairmen
of the committees.
We have put forth special energy through our
able convention committee to make the Phila-
delphia meeting an outstanding success for all
who attend.
If our efforts during the past year are accept-
able to you we are well repaid.
Public Relations
MORE PERSONS IN MENTAL THAN IN
GENERAL HOSPITALS
As an indication of the important position occu-
pied by mental and nervous diseases in relation to
the nation’s health, W. L. Treadway, assistant sur-
geon general of the Public Health Service, de-
clared in an address before the Southern Medical
Association at Louisville, Ky., recently, that ap-
proximately 324 persons in each 100,000 of the
general population are confined to hospitals for
mental and nervous diseases as compared with
192 in general hospitals, says The Modern Hos-
pital.
“Dr. Treadway pointed out that 45.7% of all
hospital beds in the United States are devoted to
the care of mental and nervous diseases, and
95.4% of these are occupied”, the writer continues.
“Last year 128,964 new patients were admitted to
these hospitals and 25,445 were readmitted. Ap-
proximately 40% of all persons applying for medi-
cal advice at public clinics or dispensaries are
suffering from some mild form of mental illness.
“For the first time in history a wider interest
is now being shown in disorders of the mind by
the public”, he said. “Failures and unconventional
behavior and conduct are being interpreted not
in terms of institutional provisions but in terms
of personality factors having behind them mental
implications.
There is a growing conviction that institutional
provision alone is an unwise and uneconomic
method of handling this group of the population.
Instead, it is being more and more generally recog-
nized that community sources of these personali-
ties must be uprooted, that mental patients must
have an early and adequate treatment, that under-
lying causes of mental diseases and adverse social
behavior must be discovered by study and investi-
gation.
“The possible solution of this situation is evolv-
ing through the development of psychiatry as a
special branch of medicine”, he said. “This special
branch of medicine, because of its knowledge of
individual needs and requirements, is equipped to
offer assistance and guidance to those groups of
the population who cannot comply with the liberal
standards of conduct maintained by society.”
NEW JERSEY PHARMACEUTICAL
ASSOCIATION
At the Annual Convention, held in Atlantic City,
June 16-19, 1931, the following resolutions were
unanimously adopted, and a copy was supplied to
the Executive Secretary of the Medical Society
of New Jersey, who was officially representing
the Medical Society at that Convention, for publi-
cation in the Journal:
Resolution No. 1
Whereas it is becoming a rapidly growing prac-
tice among pharmaceutical manufacturers to com-
pound various well-known formulas and introduce
them to the medical profession under proprietary
names ; and
Whereas such preparations contain ingredients
of known and definite standards and which are
usually found in all prescription departments of
the drug stores; and
Whereas the pharmacist is capable of compound-
ing these preparations without any difficulty, and
Whereas the introduction of these preparations
under proprietary names, and in easily identified
packages, designs or colors, increases the ten-
dency to self-medication, since usually these pro-
prietary names are of such character qs to be
perfectly legible to the lay public, and
Whereas the recommendations of these prepara-
tions through prescribing, by the medical profes-
sion, is accepted by the public as an unqualified
endorsement for the preparation,
Be It Resolved: That the New Jersey Pharma-
ceutical Association, in the interests of a closer
cooperation among the physician, pharmacist and
patient, deprecates the practice of prescribing,
recommending and fostering the use of such
preparations under proprietary names.
Resolution No. 2
Whereas the quality and standard of all U. S.
P. & N. F. preparations must conform with the
requirements of the United States Pharmacopoeia
and National Formulary, and
G 72
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
Whereas the letters U. S. P. & N. F. have been
symbolic of the professional pursuit of the phar-
macist; and
Whereas the sale of such preparations under
the name of the pharmacist has served as one of
the remaining links whereby the public has be-
come acquainted with the professional and ethical
side of the business of the pharmacist; and
Whereas the market for U. S. P. & N. F.
preparations has been made primarily through ef-
forts of the pharmacist; and
Whereas it is becoming the practice of certain
pharmaceutical manufacturers who derive their
business from the pharmacist, to advertise U. S. P.
& N. F. preparations under the manufacturers’
brand, and-
Whereas such advertising is designed to create
in the mind of the public the impression that such
preparations are in the same category as patent
or proprietary medicines; and
Whereas such advertising also tends to create
in the mind of the public that unless such prepara-
tion bears the manufacturers’ label it may be an
inferior product; and
Whereas such practice compels the pharmacist to
carry an unwarranted duplication of stock; and
Whereas all of such practices are inimical to the
profession of pharmacy :
Be It Resolved : That the New Jersey Pharma-
ceutical Association is opposed to the advertising
to the public of U. S. P. & N. F. preparations under
the manufacturers’ brand or label.
STAGING A HEAI/TH DRIVE AMONG PRE-
SCHOOL CHILDREN
(From the Bulletin of the State Department of
Health we have selected an item which is not only
of general interest but which records a bit of his-
tory that may serve well as an example for other
towns and counties of this state. If every local
committee that was left in charge of the Anti-
diphtheria Campaign will adopt, adjust to its own
needs, and follow this procedure actively. New
Jersey can be rid of diphtheria in short order. —
Ed.)
Woftien of Woodbury, Gloucester County, re-
cently conducted a campaign to induce parents to
have the smaller children of the city protected
against diphtheria.
Diphtheria prevention clinics have been held in
the city since 1923 and were patronized by some
1400 youngsters. About 70 children below school
age also attended these clinics, but no systematic
effort was made to get young children immunized
until the 4 groups of the local Parent-Teacher As-
sociation undertook the task a few months ago.
The Visiting Nurse Association joined in this drive
and together they worked out what the department
terms an admirable type of campaign.
First, approval of the local physicians was ob-
tained for the proposed plan. The Board of Health
also approved and gave a statement for publica-
tion in a local paper. Various organizations were
reached through speakers or messages and their
endorsements published. Two doctors besides the
school medical inspector wrote short articles for
the paper. Publicity also included motion pictures
and suitable literature.
Finally the city was divided into districts by the
Parent-Teacher Association leaders, and canvas-
sers were assigned to make house-to-house visits.
Parents were urged to take pre-school children
either to family physicians or to the clinic for
treatment.
This canvass resulted in a list of well over 200
names of children to be immunized. The committee
notified each doctor of those whom he might ex-
pect to be brought to him. At the first pre-school
clinic held, 102 children received their initial dose
of toxoid, which is being used in place of toxin-
antitoxin for this group.
THE ST PERTRA1 N EI) NURSE
(From the Indiana Journal, June 1931.)
We have been asked why The Journal is op-
posed to advanced education and training for
nurses. We thought that question had been
answered in comments made heretofore, but we
are very glad to say a few words more on the
subject. In the first place, while there is need
of the expertly trained nurse, yet she actually is
required in less than 5% of the cases that re-
quire nursing. The balance of the cases -will do
very well with a less highly specialized type of
service. Second, the expert nurse demands and
should have compensation in keeping with the
time and expenditure put upon her education and
training, and the quality of services that she is
rendering. The average sick person is unable to
pay for this service, and especially when, as a
result of the short hours which these highly
specialized nurses will work, it becomes necessary
to have 2 nurses. Third, for a very large per-
centage of the number of cases that actually re-
quire the services of a nurse it is quite sufficient
to have a nurse who knows how to give the gen-
eral care needed, who can follow orders, and who
can observe and report symptoms accurately. Such
nurses may be created without requiring a high
school diploma or records of college attendance,
or 3 or 4 years of supertechnical instruction such
as is given in some nursing schools that supposedly
are turning out merely general nurses. Many of
these supertrained nurses have neither had nor
have they sought the requisite amount of prac-
tical bedside training. Fourth, there is a crying
need for thousands of old-fashioned nurses who
know enough about caring for the sick to be ex-
ceedingly useful and abundantly efficient and help-
ful to both physician and the sick without pos-
sessing so much of the supertraining that now is
demanded of every female who is licensed to nurse
or holds herself out as being a trained nurse, and
who is willing and glad to work for compensation
that is in keeping with the ability of 75% of the
sick people to pay. We have no objections of any
kind whatsoever to any high standards established
as a requisite and a requirement for the highly
trained nurse who expects to do technical or
specialized work, but we do object to compelling
all those who attempt nursing to comply with such
standards. Our plea is for a very satisfactory
and useful nurse, duly accredited, who can be
made very satisfactory to the majority of sick
persons, without this supertraining and without
costing the patient so much as the supertrained
nurse expects and should have as compensation.
We also make a plea for more nurses who are
willing to take cases as they come, just as the
ordinary physician does, instead of politely but
emphatically refusing to nurse only certain kinds
of cases, to nurse only in a hospital, or perhaps
August, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
673
refusing to nurse at all unless the eases and con-
ditions relating thereto meet with exacting re-
quirements. Lastly, we are in favor of hourly
nursing in the home and group nursing in the
hospital by graduate nurses when needed, thus
making it possible for more people in moderate
financial circumstances to afford the graduate
nurse.
School Health Department
PUPIL SUPERVISION
Allen G. Ireland, M.D.,
Director of Physical and Health Education, State
Department of Public Instruction, Trenton, N. J.
Home Visiting
Nurses are frequently required to visit the
homes of pupils absent from school for unknown
cause. The value lies in the first-hand informa-
tion obtained and in the opportunity of imparting
instructions to the mother. However, attendance
work should not be allowed to interfere with other
duties of the nurse.
By having attendance officers report to the
nurse daily, it is possible to keep a check on all
absences. The period allowed to elapse before
following-up an absence should rarely exceed 2
days.
Keeping Schools Open
Detection of new cases and contacts is facili-
tated by keeping schools open in time of epidemic.
With proper precautions, the amount of exposure
at school can be kept at a minimum:; less, it is
thought, than occurs among children when schools
are closed.
With pupils at school, it is possible to hold in-
spections once a day, or more often if desired. It
is possible to train and instruct pupils at such
times in how to protect themselves, and in what
to tell their parents. It is also possible to keep
an accurate check on progress of the epidemic
and the measures in operation for checking it.
Cooperation in Disease Control
Effective disease control depends to no little
extent upon the cooperation among physicians,
health officials, and the school personnel. The
purpose and the program of the school should be
made known to the practitioners of a community.
It is especially important to have the rules for
exclusion and readmission understood. Rigid en-
forcement can only be effected when local physi-
cians uphold the school in its efforts to prevent
spread of the disease.
A system of interdepartmental reports is essen-
tial. The exchange should be daily, the school
officials reporting exclusions and suspects, and the
health officials reporting cases in the community.
Similarly, school nurses and community nurses
should establish a working basis for exchange of
information and, in particular, a procedure for co-
operating when an epidemic is threatened.
Emergencies at School
It is well to be prepared for emergencies and
epidemics. A program of procedure should be
carefully planned, put into definite form, printed,
and circularized. Every person in the school sys-
tem should know his part letter perfect.
The latest telephone directory should be avail-
able. In cases where both parents work away
from home during the day, it may be of value to
know where and how one or both may be reached.
The addresses and telephone numbers of several
physicians residing nearest to the school, including
the school physician, should be typed on a card
and placed near the telephone and in sight. The
telephone numbers of the nearest taxicab station,,
of the nearest hospital, and of the nearest garage
where an ambulance or other conveyance may
be engaged, should also be placed in a conspicuous,
and permanent place known to all.
State Health Department
SPOTTED FEVER
D. C. Bowen, Director of Health
New Jersey State Department of Health
Trenton, N. J.
A case of spotted fever has been diagnosed in
New Jersey and confirmed by the State Depart-
ment of Health and the United States Public
Health Service. The disease is new for New Jersey
and attention of physicians is called to its dis-
covery so that practitioners may be on the look-
out for other instances.
The case recently discovered was in a farmer,
32 years old, residing in the vicinity of Port Mott,
Salem County. The infection is transmitted by
the bite of a blood-sucking tick, and a definite his-
tory was obtained that this farmer had been bitten
by a tick. The investigators learned that the
victim had not been more than a few miles away
from the immediate vicinity of his home, and the
authorities were satisfied that the infection oc-
curred locally.
In the onset of this disease the symptoms re-
semble those of epidemic cerebrospinal meningitis.
A few days after onset an eruption appears, most
apparent upon the wrists, hands, lower legs, feet
and back of the victim. The disease has not been
declared reportable to the state authorities in
New Jersey, but services of the State Department
of Health were sought and an investigation made.
The state authorities called in a representative of
the United States Public Health Service, and the
diagnosis of the disease as spotted fever was con-
firmed.
The patient was first taken ill May 23 and was
moved to a hospital 3 days later. The eruption
was first noticed May 27. The case was a relatively
mild one although 2 weeks after onset of the ill-
ness the patient’s hearing was still affected and
he was subject to dizziness.
According to the United States Public Health
Service, the commonest symptoms at the height
of the disease are, in order of frequency, as fol-
lows; Prostration; headache, usually frontal; con-
stipation; nausea and vomiting (more frequent in
the Rocky Mountain spotted fever type) ; low
backache and leg pains; unproductive cough. In
the Rocky Mountain spotted fever type, pain in
the back of the neck, and abdominal pains were
not uncommon. Sweating was not uncommon.
Rare symptoms were epistaxis and dysuria.
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 1931
6 74
Communications
To the Editor:
The enclosed manuscript is sent you in order
that you may know something of what the dental
profession is doing in a field in which we believe
all branches of the medical profession are interest-
ed. The Committee on the Study of Dental Prac-
tice agreed that in the proposed investigation of
medical insurance to attempt the separation of the
dental from the medical phases would be impossible.
The interests of the professions concerned are not
and cannot be disassociated. Therefore, it is
fundamental for the dental profession to realize
that whatever happens to the medical profession
is, for the dental profession, in the nature of a
prediction.
ARE WE FACING SOCIAL CONTROL OF
MEDICAL PRACTICE ?
(Signed by the Committee on Study of Dental
Practice, H. E. Phillips, D.D.S., Chairman.)
Call it “Sickness” or "Health Insui-ance” the
“Panel System” or “State Medicine”, no legislation
has so greatly affected so many people as that
for the social control of the treatment of disease.
No section has been so deeply affected as the dif-
ferent branches of the profession dealing with the
treatment of disease. This applies almost equally
to physicians, dentists, nurses, and to nearly all
the institutions concerned with human ills. These
various divisions of the medical profession must
suffer or profit together from the workings of such
legislation. It is impossible to separate their
fates, even in discussion, and certainly not in
programs of action. To emphasize this solidarity
the words medical profession are used to include
all those so affected.
Since Bismark compelled enactment of the first
compulsory social insurance laws in 1883, similar
laws have been enacted in practically every Euro-
pean nation, in Japan and several South Ameri-
can countries, and are under favorable considera-
tion in nearly all other countries, including Can-
ada, Australia and South Africa.
The International Labor Conference, which in-
cludes every nation belonging to the League of
Nations, at its meeting in 1927, adopted an agree-
ment binding all members to introduce compulsory
sickness insurance as soon as possible. While
much is made of the distinction between compul-
sory and voluntary systems, there are few of the
latter without some compulsory features. The dif-
ference in degree is so slight that it is hard to
draw the line between them, especially as the
voluntary systems are constantly adding compul-
sory features.
In the United States, workmen’s compensation
laws have already given us a system of compul-
sory accident insurance in all but 4 states, while
a constantly increasing number of states are ex-
tending these laws to cover “occupational dis-
eases”. Many features of compulsory insurance
treatment have also been included in recent vet-
eran's legislation. All of these measures affect
the practice of dentistry.
All forms of insurance tend to expand, to cover
new classes, to give more generous compensation,
and to extend any service once offered. In Ger-
many this tendency has reached a point where
but 5% of the medical profession is engaged in
private practice. This percentage is higher in
other countries having sickness insurance, but in
few does it reach 50%ir
This matter falls within the jurisdiction of state,
legislatures. There are 48 states and it will be a
miracle if some of them do not soon make the
experiment, especially in time of industrial de-
pression, which always produces social legislation.
Such a change would deeply affect the income,
professional standards, methods of work, freedom
of practice, all relations with patients and nearly
every other feature of the lives of all the
physicians and dentists, whether they came di-
rectly under the operation of the law or not. There
is hot dispute as to the nature of these effects.
Opponents declare that such legislation degrades
the entire healing profession; encourages mal-
ingering; reduces incomes; leads to superficial,
stereotyped treatment after hasty diagnosis; in- 1
troduces lay control of professional matters; and
generally demoralizes all relations with the patient, j
Advocates urge that it brings increased income, \
especially to the beginning practitioner; that it
brings medical care within the reach of large
masses hitherto excluded makes early diagnosis
universally possible; and leads to general better-
ment of health conditions.
Part of this disagreement is due to the multi-
tude of insurance systems. These differ, not only I
as to countries, but every system changes con- i
stantly and produces different results at different
times. In planning a program in relation to such
legislation it is of paramount importance to know
whether a certain good or evil result is inherent
in the insurance system, or is peculiar to certain
times and places. It is also important to know
whether the good results can be obtained by other
means and, especially, whether — if insurance be
pressed upon this country — it is possible for an ,
organized medical profession to secure such pro-
visions as will avoid its evils.
It is to obtain the information that will help I
the entire medical profession to meet this possible
threat, in such a way as to utilize any action that
may result to the best interests of the public and
the profession, that the Committee on the Study
of Dental Practice of the American Dental Asso-
ciation is conducting a study of all phases of sick- j
ness insurance in Europe and America. As fast
as the results of that study are available they will
be placed before the members of the American
Dental Association, and will be available at any
time in the future when such legislative pro-
posals are under consideration.
(To be continued.)
FORTY-NINTH ANNUAL REPORT OF THE
SOCIETY FOR THE RELIEF OF THE
WIDOWS AND ORPHANS OF MEDI-
CAL MEN OF NEW JERSEY
The Society is in a very healthy condition. We
have maintained our membership and have been
able to assist a number of widows and orphans
who were in need of some financial aid.
The Permanent Fund now amounts to $47,100.53,
and the income from this sum was $2,382.46. The
proceeds of the Permanent Fund, as you know,
may be used to give financial aid to the widows
and orphans of former members. As in previous
years, we have found it difficult to ascertain the
names of those who may be in need of our help.
August, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CM
so again we ask our members to communicate with
the President or Secretary regarding any widow
or orphan who is in need.
At the present time we have 498 members; 35
new members were elected and 5 have resigned.
We are sorry to report that we were obliged to
drop 17 members because of non-payment of dues.
Tour Board of Trustees always endeavors to
induce members not to allow themselves to be
dropped, because we feel we need them and they
need us: not, perhaps, for any financial reward
they may receive, but for a far better reason, the
privilege of helping others.
During the year we lost by death our faithful
Secretary, Dr. Charles D. Bennett. He was one
of our earliest members, and served for many
years as secretary. No one loved the society
more, or gave more of his time and thought to its
work and welfare. His courtesy, efficiency, and
willingness to serve in all capacities, will long
be remembered.
We regret to report the loss by death of 13
other members during the year: Drs. W. C. Lieb-
man, W. S. Washington, G. K. Dickinson, C. A.
Limeburner, E. W. Hedges, H. W. Nolte, Jean
Wolfs, Daniel McCormick, B. Van D. Hedges, R.
Kuehne, J. H. Moore, Paul Fitzgerald and F. C.
Demarest.
Dr. Edward J. Ill, on June 12, 1930, delivered an
address before the Woman’s Auxiliary to the
Medical Society of New Jersey, in which he said:
“I am thankful to be able to present some facts
which should of necessity interest you. If it is
not for your personal benefit, you should be aware
how many doctors leave their families in a desti-
tute condition and how our society has been able
to relieve much real distress.
The Society for the Relief of Widows and Or-
phans of Medical Men of New Jersey has been in
existence for 40 years. It has 500 members. At
the annual meeting on May 14, 1930, the Treasurer
reported a Permanent Fund of $44,930. The in-
come from the fund amounted to $2316.63. This
income may be distributed to such widows and or-
phans as in the opinion of the trustees is thought
wise. The trustees wish to help such as are in
need. It is not considered a charity by the trus-
tees but a right to which such widows and orphans
are entitled.
I am asking you now to present to me the names
of such widows and orphans of members, who are
in need, so that the trustees may take such action
as they think wise to give some relief. It has
been most difficult to get the names of such as
are in need. A false modesty, or let us call it
pride, may be at the bottom. Let us remember
that the needy have a right to request aid.
A few months ago, Dr. Ill mailed a copy of his
address to the wife of each medical man in New
Jersey. Through this appeal 25 new members were
obtained and we have great hopes of receiving
more.
Dr. Ill took his valuable time to do this, and
also bore the entire expense. Later, when the
Board of Trustees met and tried to reimburse him
for the expense, his answer in a quiet, gentle way
was — “No, it was a labor of love”. That is per-
haps the best motto for our society: A labor of
love.
Respectfully submitted by
W. D. Miningham, M.D.,
Secretary.
ANOTHER QUESTION OF ETHICS
(A letter received from Dr. Elias J. Marsh, of
Paterson, Treasurer of the Medical Society
of New Jersey.)
Editor of the Journal: In common, doubtless,
with many other of our members, I have received
a circular letter from a firm of stock-brokers in
Philadelphia, offering' to sell me shares in various
manufacturing pharmaceutical houses, on the
ground that “as a member of the medical profes-
sion, you are, no doubt, interested in corporations
whose products are extensively used in the prac-
tice of medicine”. Of course, stock-brokers can-
not be expected to be interested in professional
ethics, but I should like to know how our Judicial
Council, or the editor of your department of Ethics,
regards this suggestion. It seems to me intoler-
able that a physician should have an interest in
prescribing a certain article, or drug, when his
judgment tells him that another is better for his
patient in any given case. No one preparation is
the best for all cases, and no one house produces
the best preparation of every kind. It is hard
enough to control our prejudices or habits in favor
of certain articles; we should not increase the
difficulty by adding a personal interest.
Signed — E. J. Marsh.
The Editor's Answer
The Editor replied to the above letter by saying
that he, too, had received the stock-broker’s offer,
and was considering how best to present his own
opinion to members of the society; and, saying
further, that the letter (reproduced above) would
be used in this manner. So, the Editor gladly
avails himself of this opportunity to endorse Dr.
Marsh’s interpretation of our professional ethics,
and to add that he would consider acceptance of
the stock-broker’s proposition — a gross violation of
ethics. We hope none of our members will “fall
for” such a business temptation.
AN INTERESTING ITEM OF HISTORY
(Letter received from Dr. Albert S. Tenney,
of East Orange.)
To the Editor: One of my patients in West
Orange, while exploring the attic of her mother’s
home, discovered an old copy of the Saturday
Evening Post, dated February 13, 1830 — a little
more than 101 years ago. Perhaps you are aware
that this famous periodical was at that time in its
101st year. Curiously, it had not up to that time
changed its size or number of pages, of which
there were only 4, from Benjamin Franklin’s or-
iginal copy issued in 1729.
On the second page of the found copy is a
statement of deaths in “The City and Liberties of
Philadelphia” during the year 1829. “Consumption”
and “Cholera” headed the list of diseases, with
638 and 257 deaths respectively. There were only
5 deaths from “apoplexy”; but 34 from “drunken-
ness” and 94 from “Mania-a-potu” (which for our
younger readers may be translated into delirium
tremens); 280 died of “debility”: 31 of “mortifica-
tion and gangrene”; and 29 were “found dead”. It
also lists 67 deaths from “hives”, which seems pe-
culiar, and gave other diagnoses which sound
strange to our ears.
676
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 19 31
Woman’s Auxiliary
PANORAMIC VIEW OF THE WOMAN’S AUX-
ILIARY TO THE A. M. A. IN FOUR
ARTICLES
No. 4. Western District
Mrs. James F. Percy
As my division in the organization work covers
the states of the far West, branching to the middle
states only to include Nebraska, this panorama
will begin there. We have been enjoined for so
many years to “Go West", that it has now become
a favorite direction of travel.
Nebraska is always up and doing, and a survey
of activities of 1931 shows an extensive distribu-
tion of the National Auxiliary Study Envelope on
“Communicable Disease Control”; much welfare
work, especially providing professional visiting
nurses for public schools in various counties and
definite organization of county relief work at a
great saving to the County Commissioners. Here,
indeed, is a far-reaching benefit for the commun-
ity-at-large in a practical, economic way. Bene-
fits are held to procure funds for completing files
of scientific books and magazines and research
work of the pathologic laboratory connected with
the Sharp Building Library, at Lincoln. The Aux-
iliaries’ scientific educational programs contain
many important names, which, together with social
and philanthropic activities, keep everyone inter-
ested, useful and happy. One new county auxiliary
has been reported as a last gift to this administra-
tion.
Colorado has kept up the interest aroused dur-
ing the national presidency of Mrs. F. P. Gengen-
bach, of Denver, particularly with spreading ideas
of good and better health through the use of litera-
ture in the less populated districts. Included with
this, “study envelopes” have been used, and a
greater field developed for approved health pro-
grams in other organizations. Growth in numbers
has not been sought so much as growth in
achievements.
Wyoming must be passed as having been silent
to all requests for even a hint as to its status.
Geographically, Wyoming and Utah are difficult
of organization, but within the few years that lie
immediately ahead they are certain to be caught
in the vibration already swinging its way through-
out the land and we feel sure they cannot long be
resistant to its call. Utah has already given ex-
pression, through her women visiting other states,
that she is ready to take action to further a prop-
erly organized auxiliary.
New Mexico, with but 1 county, Bernalillo, or-
ganized, and far from all centers of activity, has
been an inspiration in her efforts to follow the
National precepts. Unless one has traveled the
great spaces of the deserts of the southwest, no
conception of distances can be formed. This
single county has taken up child welfare work,
shle of tuberculosis seals, enjoyed programs from
its medical men, County Health Nurses and the
State Director of Public Health, and carried the
social activities of the State Medical Society Con-
vention. It is few in numbers, but verily the
leaven quickeneth the whole loaf.
Arizona has trebled its units from 1 to 3, but has
found organization work difficult because of dis-
tances. Social features have prevailed, unless
some definite need loomed in the offing, such as
the Basic Science Bill, for the passage of which
the State Auxiliary made great effort. In a state
so filled with cults, the passing of that Bill by the
Senate was a real achievement, even though it
was finally held up in Committee. However,
nothing daunted, the members are now aroused to
the possibilities and usefulness of an auxiliary,
and experienced women are stepping forward,
willing to serve and assist in making an active,
worth-while organization.
California has been concerned, aside from or-
ganization, with establishing itself upon a per-
manent foundation through a proper Constitution
and has been able to do- this with the full sup-
port of the California Medical Association, which
is printing these Constitutions as a gift to the
State Auxiliary.
At the recent State Meeting, held in San Fran-
cisco, April 27-30, 165 women registered, with 55
delegates and 115 women seated at the annual
luncheon. The Auxiliary now feels safely estab-
lished.
The keynote of each county report was educa-
tion, but the social side, welfare work. Red Cross,
changing the position of a State Senator, creating
sentiment for a Tuberculosis Sanatorium, local
philanthropies, all had their places with the scien-
tific programs. A chart — "The Technic of Follow-
ing a Bill Through the Legislature’’ — provided a
most unique, striking and valuable object lesson
as to what we are all up against in our legisla-
tures.
A resolution was introduced, adopted, and di-
rected to the National Committee on the “High
Cost of Medical Care”, asking for a change in the
name under which that Committee functions, to
one more in accord with the facts it is study-
ing, namely: “The High Cost of Illness or Sick-
ness”. The original name implies some fault of the
medical profession: while the proposed name is
inclusive of all the various factors involved in
the problem. A copy has been sent to the Na-
tional Auxiliary asking endorsement of said reso-
lution at the Philadelphia Convention. The Cali-
fornia Medical Association is presenting a similar
resolution to the House of Delegates, A. M. A.,
whose membership now closely approaches 900.
The interest shown and the friendliness in the
social life at this Convention demonstrated a new
order which we hope has come to stay.
Oregon has chiefly concentrated upon organiza-
tion work and revival of general interest this
year, through providing the units with a list of
suggested “study topics” to encourage a similarity
of subjects. Portland has monthly meetings with
speakers who use the material contained in the
“study envelopes” and is extending her educational
and philanthropic interests as well. Temporary or-
ganization in one county is hoped to soon become
permanent, thereby increasing the number and
justifying the work of the state officers.
Washington is showing great interest to be-
come organized and after considerable correspon-
dence, it has been deemed best to have the pri-
mary action come through the State Medical Meet-
ing which takes place soon after the Philadelphia
Convention. We feel it is safe to prophesy that
Washington will be on the list of organized states
for our successor.
Idaho is listed as an organized state, but as all
letters have remained unanswered the panorama
must end here.
August, 19 31
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
677
To those who were fortunate enough to attend
the National Meeting' at Philadelphia, no further
stimulus will be needed.
Each state will be eager to carry out the aims
and the ideals of the parent organization.
We learn from those who have achieved, and
in Pennsylvania the accomplishments of the Aux-
iliary, together with the cojnplete plan for the
National Convention, will give a wide understand-
ing of a still greater organization and insure a
generally more important recognition in the days
to come.
County Society Reports
ATLANTIC COUNTY:
Atlantic City Hospital Staff
Joseph H. Marcus, M.D., P.A.C.P., Secretary
The regular monthly meeting of the General
Staff, Atlantic City Hospital, was held in the Audi-
torium June 26.
The scientific program was presented by Dr.
John S. Irvin, Director of the Dispensary, who
detailed the activities 1 of the dispensary for 1930.
Total number of dispensary visits, 35,040.
Dr. A. M. Rechtman, Associate in Orthopedic
Surgery, presented some clinical cases.
Dr. E. Harrison Hickman read a paper on “The
Problem of Tuberculosis Among Children’’, as
follows:
Within the past decade, the conception of tuber-
culosis, particularly with regard to children, has
undergone a great change and out of it has evolv-
ed the belief that tuberculosis is primarily a dis-
ease of childhood. Two distinct types of tuber-
culosis infection are now described — the primary
or childhood type, and the reinfective or adult
type. Primary infection is more common in the
child and reinfection in the adult, but either type
may occur in either period of life. Of course,
the knowledge that tuberculosis generally origi-
nates in childhood has induced special efforts at
early diagnosis and treatment to avoid the infec-
tions that occur in later life. Diagnosis of tuber-
culosis in children, by consideration of the history,
symptoms and physical signs, is no longer thought
possible, but by means of newer procedures much
may be accomplished. The tuberculin test and
x-rays are indispensable in this work, but even
these are not conclusive in themselves. The ul-
timate diagnosis rests upon correlation of all the
evidence, hence the adoption of a routine diag-
nostic procedure.
Our procedure, modeled upon that employed by
the Massachusetts Department of Public Health,
and which represents what is now generally recog-
nized as being the most effective and most eco-
nomic, provides for tuberculin test of all children.
One physician can test 200 to 300 children per day,
and 48 hours later the reactors are listed. Each
reactor is sent to a roentgenologist, and those who
show definite findings must undergo a thorough
physical examination. A full statement is given
to the parents or guardians, with recommenda-
tions, and the child is provided with appropriate
treatment. This “case finding procedure’’ has much
to recommend it, and the plan, according to Chad-
wick, works out approximately as follows: for
each 100 children, including high school pupils,
given a tuberculin test, 30 will be positive re-
actors; of these 30, when x-rayed, 5 will show ab-
normal shadows on the film which will make a
physical examination advisable. Careful physical
examination is then required for only 5 out of
each 100 children.
A word about tuberculin testing, which is the
basis of our diagnostic weeding-out process. Many
tuberculin tests have been devised and advocated,
but only 5 have had any prolonged usage. Koch’s
original test depends upon the subcutaneous in-
jection of “Old Tuberculin” in dilutions of in-
creasing strength ; now used only upon rare oc-
casions because the resultant focal and general
reactions are sometimes severe. The Moro test
is performed by rubbing an ointment, containing
50% Old Tuberculin, into the skin of the chest or
abdomen, and a positive reaction is indicated by
a papular area of redness which appears in about
24 hours; a high percentage of positive reactors
is claimed by some and it is used extensively in
Europe and to some extent in this country. The
Calmette test consists in placing a drop of 1%
Old Tuberculin directly on the conjunctive, and a
positive reaction is indicated by development of
conjunctivitis; although great reliability is claim-
ed for this test, its use is hampered by the danger
of permanent injury to the eye. One of the earli-
est, and still the most popular, of the tuberculin
tests is that devised by Von Pirquet, which has the
advantages of great simplicity and a fair degree
of accuracy; it is performed by abrading the skin
of the fore-arm and applying 1 drop of concen-
trated Old Tuberculin, and a papular area of red-
ness appearing in 12-96 hours constitutes a positive
reaction.
The test which is now supplanting all others is
that suggested by Mantoux and Mendel and which
carries the name of the former. This method
possesses several advantages. It is simple; can
be performed in a standard manner; the dose can
be accurately measured; result is easy to inter-
pret; it gives a slightly higher number of re-
actors than the Pirquet method; it is a rough in-
dex of the degree of activity; and is not harmful
to the patient.
The Mantoux test, which we use exclusively, is
the intradermal injection of Old Tuberculin in
measured dilutions; dosage in our clinic is 0.01
mgm., 0.1 mgm., and 1 mgm. Old Tuberculin in
0.1 c.c. of sterile normal salt - solution. Reactions
appear from 12-72 hours later, the greatest num-
ber occurring at about 48 hr., at which time tests
are read. If the individual does not react to the
weakest dose, he is tested successively with the
more concentrated solutions. In this way, re-
actors are often discovered after being negative
at the first reading. An important point to be
noted in reading a tuberculin reaction is that the
lesion consists of 2 parts, a central area of edema
and a surrounding zone of erythema. The redness
should be entirely disregarded, as it is believed
to be a non-specific phenomenon. In this respect
the tuberculin test must be differentiated from
the Schick and Dick tests, in which the area of
discoloration is of primary significance. In the
Mantoux test, the area of edema alone indicates
sensitization to the toxin of the tubercle bacilli.
What is the significance of the tuberculin re-
678
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
August, 19 31
action? It has been pointed out repeatedly that
it does not always denote active disease, especially
in older individuals, nor do any of the men who
now employ it make such a claim. Failure to
realize that a positive test does not constitute a
diagnosis of activity is responsible for many clini-
cal errors. A positive result does, however, indi-
cate tuberculous infection, latent, active or heal-
ing, and the younger the patient, the greater is the
probability of activity.
Intensity of the reaction is of some importance.
In general, the more active lesions are attended
by more severe response than quiescent lesions.
However, it must be admitted that this seeming
relationship is not universally accepted, for many
observers have reported quiescent cases with
severe skin reactions, and vice versa.
Prognosis and type of treatment depend upon
the extent of the disease and the child's individual
response to the disease. Based upon this, we divide
our positive cases into 3 groups.
In general, children who react to the tuberculin
test but show no roentgenograpbic evidence, those
with circumscribed calcified parenchymal nodules,
and those with healed tracheobronchial nodes, need
no special attention except periodic examinations
at intervals of 6 weeks to 1 year. In this group
the prognosis is excellent. The individuals are
regarded as healthy, and no restriction is placed
upon them.
A second group contains those children who are
in danger of tuberculosis that will undermine
health and who should receive the preventorium
form of treatment. They show first, latent lesions
of the childhood type; second, tuberculous tracheo-
bronchial nodes when contact with open tuber-
culosis is still present, when the tuberculin reac-
tion is intense or when the lesions are very large;
third, latent adult tuberculosis; fourth, arrested
pulmonary tuberculosis; and fifth, lesions of the
first group -where impaired health, perhaps not
due to tuberculosis, is present. Since February, 3
patients from this group have been sent to the
preventorium at Farmingdale, and several others
have been referred for admission.
The third group contains those children who
should receive sanatorium treatment, those who
show' both x-ray and physical signs, who show
progressive lesions on repeated x-ray examinations,
or who have massive uncalcified tracheobronchial
lymph-node involvement. Three children of this
group, with moderate activity, have been sent to
Glen Gardner and 1 advanced case to Pine Rest.
If children of the preventorium and sanatorium
groups receive proper care, they are usually able
to successfully combat the disease. However, they
sometimes succumb to an excessive infection due
to the breaking down of supposedly walled-off
tracheobronchial nodes. The presence of such
nodes should always be regarded as a potential
source of danger until the period of early adult
life is established.
I believe that tuberculosis will eventually be
treated as a public health problem. Bike diphtheria
and small-pox, it should be added to the list of
diseases that can be attacked with advantage in
the schools, and every child, whether or not sus-
pected of harboring the disease, should be ex-
amined for tuberculosis by some method similar
to the one described.
Discussion followed by Drs. Fish, Salasin, Mar-
vel, Rosenblatt. Andrews and Marcus.
CUMBERLAND COUNTY
K. S. Corson, M.D., Reporter
Dr. Reba Lloyd, President of the Society, opened
the hospitable doors of her suburban Sanatorium,
Ivy Manor, to receive as guests the members of
the County Medical Society together with several
visitors from Salem and Gloucester Counties.
An interesting report was given of the progress
of plans for the inter-county Tuberculosis Hospi-
tal. The selection of a central and suitable site
seems to be the main point to be settled.
Dr. Robert Sturr discussed the new diagnostic
features of gall-bladder and gastro-intestinal tract
disease. Discovery and use of newer dyes has made
possible the demonstration of every form of gall-
stones, and the need of surgical exploration, for
determination of the character of most diseases of
this part of the body has practically been elimi-
nated.
Dr. Graham brought out the accurate use of
dyes by the intravenous method, as they are not
then diluted by the gastric juices. Nonfilling
gall-bladder is pathologic. Stone in the com-
mon duct is less easy of detection. Gall-blad-
der function test is important, and adhesions and
surrounding fat change its features. Cardiospasm
of the pylorus may be differentiated from ulcer by
use of belladonna. Ulcers of the duodenum are
never malignant. Those of the stomach are
usually of the small penetrating type. Intestinal
obstruction is indicated by the step-ladder appear-
ance.
Dr. John H. Kolmer, wh o endears himself to
every audience by his personality and masterly
delivery of his subject, spoke on “Infection of the
Blood Stream’’.
UNION COUNTY
Russell A. Shirrefs, M.D.. Reporter
A regular meeting of the Union County Medical
Society was held on the afternoon of July 8. at
Bonnie Burn Sanatorium. Scotch Plains, with
President Vinciguerra in the chair. It was a
pleasure to have with us as distinguished guests,
Drs. John Hagerty, President; .T. B. Morrison,
Secretary, and C. C. Beling, Councilor, of the State
Medical Society; each of whom spoke and interest-
ingly outlined the work of his respective depart-
ment.
On account of the heat, routine business was
reduced to a minimum. Dr. John E. Runnells,
Superintendent of Bonnie Burn, addressed us on
the subject of “Tuberculosis”, with especial refer-
ence to compression of the lung in suitable cases.
His talk was illustrated by many x-ray pictures.
At the close of the meeting a “shore” dinner was
served in a nearby grove.
Obituaries
KOCH, Louis A., life-long resident of Newark,
and since 1902 a Newark physician specializing in
dermatology, died July 7, 1931. at the home of his
brothers, William and Paul Koch, 44 Johnson Ave-
nue. He was 53 years old.
Dr. Koch had been ill many months. He was on
the staff of the Newark City Hospital and head of
the Dermatology Department of the Newark Dis-
pensary.
Dr. Koch was graduated from the medical school
of the University of Maryland. Besides being a
member of the Newark Lodge of Elks, he belong-
ed to many medical societies.
670
Journal of The Medical Society of New J ersey
Under the Direction
of the Committee on Publicatio®
Vol. XXVIII., No. 9 ORANGE, N. J., SEPTEMBER, 1931 Year
PLASTIC SURGERY; INDICATIONS
AND RELATIONSHIP TO OTHER
SPECIALTIES
Jacques W. Maliniak, M.D.,
New York City
Plastic surgery receives equal recognition
with the other special services in every mod-
ern hospital because of the numerous condi-
tions requiring plastic repair and in the in-
terest of advancement of this relatively new
specialty. Only within comparatively recent
times have medical colleges and general hos-
pitals established services for plastic surgery,
and there is a lack of uniformity in its status
in the general hospitals ; some having organ-
ized it as an independent service, and others
having combined it with the departments of
oral surgery or of rhinolarvngology. The ne-
cessity of this special service is not as yet
realized by all medical boards, so there is need
for further enlightenment.
Preventive Measures in Injuries oe
Soft Tissues
The United States Bureau of Statistics re-
ported more than 1,000,000 injuries and 52,-
COO deaths due to automobile accidents alone
in the year 1929. A toll of approximately
10,000,000 accidents of all kinds in this coun-
try during the past year is reported by the
Metropolitan Life Insurance Company; and,
at the present rate, 100.000 automobile casual-
ties are estimated for 1931. Most of the in-
juries incurred in such accidents require medi-
cal and surgical attention. Thorough emer-
gency repair of soft tissue injuries would be
of much avail in the prevention of conspicuous
deformities, in the preservation of function,
and in the reduction of economic waste.
Hematoma, infection and inaccurate adjust-
ment of tissues tend to result in a prolonged
healing process, with undue scar formation
and disturbance of function. The healing
process of a properly treated wound requires
only a few weeks, but may be protracted to
months or years in the event of inadequate
first aid treatment, and thus cause unnecessary
suffering and economic loss.
The vast number of highway and industrial
accidents in this country demands the estab-
lishment of ^appropriate treatment facilities
in general hospitals. Emergency surgery, re-
quired in extensive lacerations of soft tissues,
particularly those about the face and neck,
should not be left to the judgment of an in-
tern, as is so often the case in general hospi-
tals, but should be supervised by a competent
plastic surgeon. If the accident occurred sev-
eral hours before the injured person was
brought to the hospital, and under unfavor-
able aseptic conditions, immediate disinfection
of the wound by moist warm dressings and
liberal use of Dakin’s solution, is the safe
procedure, postponing surgical repair for 24-
48 hr., when a culture from the wound may
prove negative. Far more satisfactory end-
results are obtained by the later repair of soft
tissues in a properly equipped operating room,
without haste and undue tension, than bv im-
mediate repair in the emergency room.
6S0
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
Surgery of Soft Tissue Defects
Burns and motor accidents cause the largest
group ot' disfigurements, the end-results of
which may affect function of the involved
part, as well as the vocational and social status
of the individual. Proper management of
burns requires the most painstaking and
elaborate reconstructive procedures in order
to secure satisfactory cosmetic and functional
results. Exposed nerves, tendons and joints
must be adequately protected by adjoining
area as nearly as possible. A pedicled skin
flap may not be available, but even when it
is, conspicuous scarring may result. Repair
of a skin defect by repeated, partial excisions
is the method of choice, and should be applied
whenever possible.
Successful reconstruction of large defects,
following cancer surgery, especially in the
maxillofacial area, encourages a more
thorough eradication of the disease and pro-
motes the chances of cure.
A.
Figure 1. (A) Nullipara, aged 22, with con-
spicuous pendulous breasts; patient suffered from
pain around the shoulders and chest. Marked ky-
phosis and faulty posture; marked mental depres-
sion.
pedicled flaps or by free full-thickness grafts.
When the involved part does not interfere
with an important function, a thick Thiersch
graft will furnish a satisfactory covering.
Full-thickness grafts often “take" on the fore-
head but usually will not on the cheek or
neck, because complete immobilization of the
region is difficult. Thin skin grafts have a
pronounced tendency to contract and, conse-
quently, should not be used in treating wounds
around the facial cavities and neck. In burns
and other extensive wounds of the face, re-
pair is to be done by use of a skin graft which
in texture and color matches the surrounding
B.
(B) Same patient 3 weeks after operation which
consisted in subcutaneous transposition of gland
with nipple, resection of fat tissue and mastopexy
to the pectoral fascia. The principal scars placed
in the submammary fold and around the nipple 1
are barely noticeable a few months after operation.
Indications for Plastic Repair of
Pendulous Breasts
Until recently, reconstructive surgery of
pendulous, hypertrophic and atrophic breasts
has been largely neglected, particularly in this
country. A review of the literature of the
past 2 decades reveals a great interest in the
subject by leading European surgeons. Surgi-
cal procedures for relief of this condition have
been described by recognized authorities, and
the best method for correction of hypertrophic
and atrophic prolapsed breasts is the subcu-
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
681
taneous transposition of the gland with masto-
pexy. (Fig. 1.)
Indications for Plastic Repair Around
Facial Cavities
Nose. For successful performance of rhino-
plasties. training in general surgery as well
as in rhinology, and a sense of proportion
and harmony, are essential. As the rhinol-
ogist does not always possess these qualifica-
tions, and, moreover, as aseptic facilities are
often lacking in a nose and throat operating
A.
Figure 2. (A) Female, aged 20, with conspicuous
depressed type of congenital nasal deformity and
double epic-anthus, causing a Chinese facial ex-
pression. Patient suffered from a marked mental
depression.
room, association of plastic surgery with the
rhinolaryngologic service in a general hospi-
tal is not a satisfactory provision. The need
for partial and total nasal reconstruction can
he fully appreciated only by those who deal
with patients requiring such repair.
In addition to corrective partial and total
rhinoplasties, reconstructive surgery is indi-
cated in atrophic rhinitis, in narrowing of the
nasal cavities bv transplantation of cartilage
into the septum and floor of the nose, in
atresias, and in other nasal impairments. Cor-
rection of congenital or acquired nasal de-
formities, performed with proper skill and
under strict asepsis, should be uniformly fol-
lowed by satisfactory functional and cosmetic
end-results. (Fig. 2.)
Ear. Indications for otoplasties and for
closure of large defects following mastoidec-
tomies are of less frequent occurrence than
for other forms of facial repair. While partial
plastic repair of the ear is accomplished with
comparative ease, from the standpoint of encl-
B.
(B) Correction of deformity by a thick rib car-
tilage transplant which corrected the nasal de-
pression as well as the epicanthus.
results there is need for improvement in total
reconstruction.
Orbit. Surgery of congenital and acquired
deformities around the orbit is of vital im-
portance as its purpose usually is not only to
correct the disfigurement but, especially, to re-
establish the disturbed function. The majority
of ophthalmologists do not perform plastic
operations in the orbital region, but some of
them show great skill in such corrective sur-
gery and have contributed much to its de-
velopment. The most frequent indications for
G82
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
plastic repair in this region grow out of cicat-
ricial contractions around the eyelid and eye-
socket due to accidental injuries.
The shifting of skin flaps from the adjoin-
ing area, and the use of free skin grafts, en-
counter far greater difficulties in the orbital
region than elsewhere, because of the varieties
of skin-covering required and the functional
significance of the eyelids. To obtain satisfac-
tory anatomic and physiologic restoration in
this area, a thick skin graft must be used for
the forehead, hair-bearing skin for the eye-
brow, and a graft of fine texture for the eye-
lids.
A.
Figure 4. (A) Right unilateral incomplete cleft
lip with flattening’ of the nostril.
Cleft Lip and Cleft Palate From the func-
tional and cosmetic points of view, too fre-
quently the end-results in operations perform-
ed for cleft lip and cleft palate leave much
to be desired, despite the surgical progress
made during the past 2 decades. The technic
available for repair of a cleft lip deformity is
today of such precision that further failures
should not occur. In the more complicated
types, the operation should be done in succes-
sive stages. The factors necessary for success-
ful end-results are : proper outlining of flaps
provided with adequate blood supply ; suffi-
cient undermining of the surrounding skin
and mucous membrane ; avoidance of tension ;
and the use of fine suture material. (Fig. 4.)
The operation for cleft lip should be done
from 4 to 5 weeks after birth, and the palate i
should be closed at the age of 12 to 18 months,
To assure good functional results, the chil-
dren should receive early and competent
speech training.
Skin Malformation. A nevus hemangioma,
lymphangioma, fibroid, hairy mole, or an area
of pigmented skin may be eradicated by re-
peated excisions, without leaving a trace of
the surgical intervention except a linear scar.
If shifting of an adjoining skin area cannot
be accomplished, free or pedicled skin grafts
can be used. If indicated, plastic surgery may
be supplemented by the application of x-rays
B.
(B) Condition 0 months after cleft lip repair,
done at the age of 6 weeks.
or radium. Although in these skin affections
radiation alone sometimes results in partial
improvement, this therapeutic measure is fre-
quently misused. Prolonged irradiation is al-
ways followed by scarred skin, which con-
trasts conspicuously with the surrounding
area. Moreover, the prolonged treatment of
skin blemishes by radiation exclusively is a
great economic waste, causes the patient much
mental distress and rarely completely eradi-
cates the deformity.
Summary
(1) Plastic surgery has become an indis-
pensable surgical unit in the general hospital.
(2) Inclusion of plastic surgery in other
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
633
departments of general hospitals is inadvis-
able.
(3) The many problems involved in the
Figure 6. (A) Partial loss of nose resulting from
galvanoc-auterization of rhinophyma.
plastic surgery and should be undertaken only
by a qualified specialist.
(4) The successful reconstruction of
highly hypertrophic and atrophic prolapsed
breasts is assured by the method of sub-
cutaneous transposition of the gland.
(5) The end-results in rhinoplasties are
uniformly successful if the surgical procedure
is carried out aseptically and with proper skill.
(6) Intricacies involved in the plastic re-
pair of the orbital region are due to the dif-
ferent types of skin grafts required in a rela-
tively limited area and to the functional im-
portance of the eyelids.
(7) Cleft lip and cleft palate, if repaired
at an early age, should be followed by satis-
factory end-results in the majority of cases.
(8) variety of skin affections can be
B.
(B) Delayed tubed temporal flap, the distal end
of which is sutured into the nasal defect and
sutured to the flap : the lining of the nose was
provided by the nasal skin from above the defect,
rotated downwards.
*Maliniak, J. W. : Rhinophyma — -
Its Treatment and Complications.
Archives of Otolaryngology. Feb.
1931, Vol. 13, pp. 270-274.
prevention and correction of deformities from successfully treated, and with the avoidance
soft tissue wounds caused by bums and motor of great economic loss, by plastic procedures
accidents require a thorough knowledge of followed, when necessary, by radiation.
684
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
SOME DIFFICULTIES OF THE
ASTHMA PROBLEM*
George H. Lathrope, M.D.,
Newark, N. J.
Much is known about hay-fever. Com-
paratively little is known about asthma. Of
its etiology, its pathogenesis, the mechanism
of its crises — some brief, others severe and
prolonged into weeks and months, even lethal
— of its therapy, little of a conclusive sort is
known. And yet, 10 years ago, with the
therapeutic solution of hay-fever in the hands
of the profession, hope ran high that solution
of the asthma problem also was at hand. To-
day it seems as distant as ever.
Hay-fever and asthma are so commonly
conjoined in the professional mind, that the
mention of one usually evokes the idea of the
other: wherefore, it may be well to mention
briefly some of their similarities and contrast-
ing features.
Hay-fever is an allergic manifestation.
Supposedly so is asthma — sometimes. Season-
al incidence is the striking characteristic of
hay-fever; as an attribute of asthma it is only
occasional. Hay-fever is marked by tur-
gescence and watery discharge from the
mucous membrane of the upper respiratory
tract, with eosinophiles present in the dis-
charge and in the blood stream. It is sup-
posed that asthma presents a similar picture
in the bronchial mucosa. Hay-fever par-
oxysms may be temporarily relieved by adren-
alin. Some asthmatic crises are similarly
affected. Hav-fever is caused largely by sen-
sitivity to pollens. Certain cases of asthma
have the same apparent background. Treat-
ment by pollen solutions improves a great
number of cases of hay- fever. It helps a few
cases of asthma.
On the other hand, a considerable number
of asthmatics have their first attack as the
result of a respiratory infection ; and no mat-
ter what the origin of asthma, there is prac-
*(Read before the Morris County Medical So-
ciety, March 12, 1931, as part of a symposium on
asthma.)
tically always, after the lapse of time, an in-
fective element present, which apparently may
come to overshadow all else. Some asth-
matics display a pollen sensitization without
ever having had hay-fever. Some have hay-
fever first and then develop asthma. Others,
asthmatic from the beginning, display no skin
reactions whatever suggestive of an allergic
condition. Practically all, sooner or later,
show evidence of bronchial tract infection,
and it is this fact which makes therapy by
bacterial vaccines of distinct though limited
value.
Clinical Description. T*he usual clinical his-
tory and course of the cases which yield more
or less satisfactorily to treatment may be de-
scribed as follows: In the history there may
be shown a familial allergic tendency — asth-
ma. hay-fever, eczema, etc. The patient has
had asthma for a varying time from a few
months to 20 years. It may have been pre-
ceded by hay-fever, and the first asthmatic
attack may have come in the hay- fever season
while symptoms were at their height. On the
other hand, no family history of allergy may
be obtained, and the patient has never had
hay-fever. The first asthmatic attack de-
veloped during a severe cold, and every suc-
ceeding attack has apparently been the result
of what began as a so-called .“cold”.
The paroxysms in one case may be brief
and easily controlled by adrenalin, their noc-
turnal recurrences continuing only a week or
two. In another the paroxysms are febrile,
and may be prolonged into a distressing pic-
ture of constant dyspnea day and night, re-
lieved only when the patient’s vital force
seems so depleted as no longer to be able to
endure the strain. Utter exhaustion brings a
brief respite of 2 or 3 hours sleep, from which
the patient wakes at first refreshed, only to be-
gin another paroxysm which goes on to renew-
ed exhaustion. The picture is one of a true
status asthmaticus which may last weeks or
even months, entailing an amount of suffering
which seems unendurable. Such severe status
conditions come once or twice a year with only
comparative comfort in the intermissions; for
these patients are definite chronic fatigue in-
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
685
valids and incapable at their best of the ef-
fort of healthy individuals.
The cases with brief paroxysms, and in
general of the mild type, are apt to obtain
prompt relief of the paroxysm with 1 or 2
hypodermics of adrenalin. The discovery of
a pollen or other sensitization and the admin-
istration of appropriate treatment may prove
very efficacious. In other cases where an in-
fective element was evident from the start, or
where it has crept in after several years of
successive attacks, the culture of sputum, of
sinus washings, or of tonsils, yields a growth
from which a vaccine may be developed whose
efficacy in improving the patient’s condition
is more or less gratifying.
The discouraging feature of most of these
cases is that the attacks, despite temporary
relief by treatment, keep recurring, and the
patient and physician must be always on the
alert for the first evidence of trouble as the
signal for renewing treatment. Curing the
crises or attacks has not cured the disease;
and, as has been suggested above, the patient
all too often is still, between attacks, an in-
dividual much below the normal standards of
health.
It seems evident then that direct attack
upon the asthmatic crisis is only a partial
measure ; and this leads to an inquiry into the
pathology of asthma, and to a consideration
of some of the questions which arise out of
any effort to solve the asthma problem.
Pathology. Death from uncomplicated asth-
ma is comparatively infrequent. Rackemann,
in his monograph just published, has collected
only 12 reported autopsies — 3 of them among
his own series. These reports reveal 2 types
of lesion. The one shows an hypertrophy of
the smooth muscle of the smaller bronchi ; the
other, hypertrophy of the mucous membrane
and mucous glands. Both types are apt to be
found in the same subject, but one or the
other may be distinctly dominant. Emphysema
is an almost constant finding in every case,
and eosinophiles are scattered through the
mucous membrane. The cases with muscular
hypertrophy as the main lesion are supposedly
those whose crises were due to bronchospasm
and were most susceptible to the influence of
adrenalin, and they represent essentially the
type of asthma due to some outside agent ;
while those with an hypertrophied mucous
membrane are the ones less amenable to adren-
alin, and belong more often to the group as-
sociated with bacterial infection. While this
statement is in the main true of the 2 types
where they can be readily distinguished, it
must be understood that admixture of the
types is common and a dividing line may be
hard to define.
Study of our own cases, based on roent-
genograms and physical findings, indicates
that chronic bronchitis, pleurisy, particularly
at the bases, and bronchiectasis should be in-
cluded in the pathology of asthma. Bron-
chiectasis is not uncommon, and is of import-
ance because it may easily constitute a focus
of infection of no inconsiderable proportions.
This local condition of hypertrophy of the
bronchial musculature and mucosa is ap-
parently the important factor in the asthmatic
crises. Just what is back of it is another
matter. Hypertrophy is perhaps merely the
local response to repeated attacks, just as em-
physema is another pathologic feature which
develops from constant renewal of attacks in
the course of time.
In those cases chiefly marked by broncho-
spasm and without much chronic thickening
of the bronchial mucosa, adrenalin may give
prompt and marked relief. This apparently is
to be regarded as evidence that sympathetic
depression or vagus irritability is the cause
of the bronchospasm, for adrenalin is known
to be a powerful sympathetic accelerator. It
is possible that whatever disturbs the vagus-
sympathetic balance may be a potential factor
for production of the asthmatic attacks, and
causes for such disturbance are probably num-
erous. Hypersensitiveness to antigens, pollen
or bacteria is only one factor, albeit the one
best known, and, to date, most important in
this connection.
Irregular clinical types. Properly speaking,
asthma is a symptom, not the disease entity in
itself. We should not confine ourselves to
treating asthma; we should treat the patient
who suffers from asthma; just as we treat
the patient who suffers from indigestion, and
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
686
search for ulcer, cholecystitis, cardiac incom-
petence. or other cause. The cases with hvper-
sensitiveness to antigens have been outlined.
But other and confusing elements, apparently
outside the range of what is known as allergy,
creep into view. This leads to a considera-
tion of what may be called irregular types of
asthma; i.e. those cases which show some ele-
ment or elements beside allergic or bacterial
activity; and such are all too frequent.
In a given case, let us say a timothy sensi-
tization is discovered and appropriate treat-
ment does much to ameliorate the attacks.
However, they persist, and then a bacterial
vaccine is employed which for a time works
wonders. Nevertheless, there is an annoying
residue and tendency to paroxysms which will
not down until a weakened heart muscle is
recognized and braced up with digitalis, or
an hypertension has been relieved by prolong-
ed rest in bed and simple diet. Then only,
and thereafter only at the price of constant
care of the circulatory apparatus, does the
asthmatic phase really recede into the back-
ground, though it never completely disappears.
Another case yields unsatisfactorily to the
usual methods of treatment, until a laparot-
omy becomes necessary for fibroid, ovarian
cyst, or some gastro-intestinal lesion, when the
asthmatic condition is promptly relieved.
Certain methods of treatment must be noted
as revealing further vagaries of the problem.
The mechanism of 2 of these is essentially
similar, viz.: (1) Relief by diet which is
really a starvation process; and (2) relief by
the exhibition of nitrohydrochloric acid as re-
ported by Beckman, in the Jour. A. M. A., for
November 22, 1930. The asthmatic patient
supposedly develops an alkalosis, and starva-
tion on the one hand, or the addition of some
acid body to the food intake on the other,
brings about a diminished alkaline reserve
with a concomitant relief of the asthmatic
condition.
Treatment of asthmatic attacks with acetyl-
salicvlate and with whisky has met with more
or less success in times past, and their utility
is impossible of explanation on the basis of
anything we know at present about allergy or
infection.
A more striking method of therapy is re-
ported by Knott, Oriel and Witts, in Guy’s
Hospital Reports for October. 1930. Thev
give the report for the Asthma Clinic for the
years 1928-30, which embraces a study of
205 cases. Curiously enough, from our stand-
point at least, little or no effort was made in
this series to employ antigens, pollen, bac-
terial or other, nor is that side of the problem
much stressed.
Their sole treatment was an ounce of glu-
cose in water, with lemon or orange juice,
given on an empty stomach twice daily.
Their figures are :
Under 9 yr. of age 22 of 26, cured or improved
10-19 yr. of age 23 of 31, cured or improved
20-29 yr. of age 9 of 18, cured or improved
30-49 yr. of age 6 of 22, cured or improved
The added infective element with increasing
age is held to be the factor lowering the in-
cidence of relief. They attribute this relief
to the fact that the liver plays a large part in
antigen-antibody reactions, and that it func-
tions best when supplied with glucose. Thus
are added still other factors making for con-
fusion in the present current ideas of the
pathogenesis of this condition. Environmental
and climatic conditions have an important
role. One patient finds relief at sea, another
in the mountains, another in the plateau coun-
try of the Southwest, or in the dry sea-level
air of lower Egypt. These are not necessarily
pure pollen or bacterial cases. Some factor
in climate other than the absence of pollen or
dust which has an influence on the human or-
ganism is probably in play. Perhaps the ultra-
violet sun rays have a part in these cures.
Perhaps some stimulating effect on the thyroid
or other endocrine glands is a potent influence.
Many asthmatics, as indeed many patients with
chronic infection, are distinctly hypothyroid.
Others are too evidently susceptible to emotion-
al influences, and relief from business worry,
from the strain and irritations of ill adjusted
domestic environment, is a curative measure
which should not be neglected wherever pos-
sible to accomplish it. Emotion, together with
physical and mental overstrain, are recognized
factors in upsetting the nervous mechanism,
exhausting the endocrines, and disturbing the
vagus-svmpathetic balance.
And finally, it must be noted that a long
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
6S7
recognized peculiarity of asthma is its quies-
cence during pneumonia or other severe in-
fections, as well as its tendency to he minim-
ized, if not altogether absent, during preg-
nancy. What is this common dominator which
places pregnancy and pneumonia side by side
as incompatibles of asthma? No satisfactory
answer to this question has as yet been given ;
though Beckman endeavors to explain both
phenomena by his alkalosis theory.
Every case of asthma needs careful and
prolonged study. It can rarely be solved in
one sitting. Complete understanding of the
individual case is an ideal rarely attained, and
observation for months, and through a varied
assortment of conditions, is usually needed
for any understanding whatever.
It is perhaps not too much outside the
bounds of probability to summarize the situa-
tion as to this subject as follows:
The allergic mechanism in its essence is to
be regarded as a normal part of the physiology
of every individual. It is not unlikely that it
is an important part of the protective me-
chanism. In certain individuals there is a
constitutional or hereditary disposition to
over-react in this respect, so that we come to
recognize and speak of an allergic type. I his
abnormal sensitiveness to stimuli which may
produce allergic reactions is probably the fun-
damental factor in asthma; but, as has been
pointed out, such stimuli are numerous, and
so far as our present knowledge goes, appar-
ently quite dissimilar. We have nitrogenous
bodies on the one hand, such as pollen, dust,
animal emanations, and bacterial products,
which seem to be direct in their action ; and on
the other such vague conditions as climatol-
ogic influence, emotional states, endocrine
disturbances, maladjustment of the acid base
balance, and factors causing disorientation of
the vagus-sympathetic mechanism. I he pic-
ture is still inchoate, and has great need for
synthesis and coordination.
If this has seemed a discouraging or pessi-
mistic presentation, it is a warning against
over-confidence and too optimistic prognosis,
both of which weaken investigative curiosity.
The mind must be kept open and ready for
suggestions no matter how bizarre they may
seem at first sight. Ignorance of the subject
is so great that there should be no astonish-
ment or disbelief when one investigator re-
ports cases cured by nitrohydrochloric acid,
or another reports cure or improvement fol-
lowing laparotomy. We accept with little
question the vagaries of the beneficial effect
from change of climate, yet who can say what
may be the mechanism of the improvement
thus brought about?
The present methods of attack are largely
based on the removal of focal infections, the
use of bacterial vaccines, of pollen or other
antigens, and change of climate and environ-
ment. But these methods are all too inade-
quate; and the reasons for that inadequacy,
like the Holy Grail, are still to seek.
THE DUST FACTOR AND THE BAC-
TERIAL FACTOR IN ASTHMA*
Royce Paddock, M.D.,
Newark, N. J.
The importance of dividing asthma into 2
main groups lies in the different kind of
treatment to he attempted. It is our view
that a majority of cases of asthma give evi-
dence of bacterial infection of the respiratory
system. This is usually in addition to allergic
hypersensitiveness to outside dust factors,
such as pollens, powders, house dust, and ani-
mal epidermal substances. We are familiar
enough with the cases which are described in
the literature, cases of asthma found to be
clinically hypersensitive to horse dander, cat
hair, feathers, or orris root used in face
powder. The outside factor is removed, and
the patient’s symptom disappears. In every-
day experience cases of this kind are not com-
mon. We find the cause difficult to discover,
and the symptom apt to continue. It is plain
that the practical application of the methods
of finding and removing the outside causes
is in these every-day cases difficult and ted-
ious. The patient does not recognize any
outside factor as causing his symptom, or if
* (Read before the Morris County Medical So-
ciety, March 12, 1931, as part of a symposium on
asthma.)
C8S
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
lie does, and the skin test is positive, removal
of the supposedly offending substance does
not produce the desired result. The obstacles,
as we see them, are mainly 2 : the difficulty
caused by the multitude of causes, and that
caused by the presence of infection. They are
to be attacked by different methods.
Multiple outside factors. The allergic dia-
thesis, or whatever constitutional predisposi-
tion we assume for the clinical forms of al-
lergy. such as asthma, does lead to the de-
velopment of hypersensitiveness to more than
1 outside cause in many cases. We should re-
member that probably about 500 different sub-
stances, mainly from the animal and vege-
table kingdoms, can be listed as outside causes
of the various clinical forms of allergy. The
allergic individual is exposed to many possible
exciting causes, and chance would seem in
favor of development of the allergic response
to several. Although the common causes of
hypersensitiveness are relatively few com-
pared with the total, there are supposedly
many still undiscovered, as each year’s ad-
dition to the list would show. We may group
them practically under such convenient heads
as household dust substances, industrial dust
substances, outdoor dust substances (such as
pollen), meaning by dust any small particle
of material that will float in the air. Inorganic
dust is of secondary importance, as it does
not, so far as we know, produce an allergic
response, though it may aggravate it.
On account of this multiplicity of exciting
causes complicating the problem of diagnosis,
the attempt to find the specific exciting cause
or causes suffers by comparison with anv
method which would be applicable to all cases.
Status of drug therapy. Of such means
we first have the ability to cut short the asth-
matic response by drug action. With all the
various possible outside factors which may be
the exciting cause, the asthmatic attack varies
little in its essential features, though the time,
and place, and other circumstances which
bring it on vary a great deal. The attack
usually responds to the proper drug, in this
case adrenalin, or epinephrin, with a prompt
and satisfactory relief of the symptom, in
spite of the various causative factors which
are at work. This relief is practically always
temporary, and continued use of the drug
often leads to an undesired diminution in the
response which further limits the result of its
use. But this drug is a reliable aid.
Another drug with much the same effect,
used widely in at least 1 patent medicine, and
usually without a doctor’s advice, is cocain, in
weak solution. Carried in a spray by many
patients, it cuts short the attack and enables
them to do work which would otherwise be
impossible.
Use of patient's own household dust in
diagnosis and treatment. Although these aids
are in wide use, the first aim of those who are
trying to control and prevent asthmatic at-
tacks is of course to find the specific outside
factor or exciting cause, if this is possible.
This at present is our best chance of effecting
permanent relief, and should be considered
first. If the skin tests and history are both
negative in regard to specific cases (and it is
not usually practicable to try more than 20 or
30 at a sitting, or less in the case of a child),
it is advisable to test the patient with his own
household dust. The dust is obtained, prefer-
ably from a vacuum cleaner used in the pa-
tient’s own room and the parts of the house
frequented by him. Sweeping is inferior
because of coarse dust collected. The finer
portion of the sample is taken. According to
the method of Cooke and Coca, after this col-
lection and separation, the finer dust is ex-
tracted, after removal of grease by means of
ether. The extracting fluid is prepared ac-
cording to Coca’s formula, by adding a small
amount of sodium bicarbonate to 0.5% saline,
the extraction being continued for 48 hours
under toluene. The extract is then drawn
through a filter of the Berkfeld type and cul-
tured to test for the absence of aerobic and
anaerobic bacteria. Heat sterilization cannot
be used on account of the destruction by heat
of the substances extracted. About 0.05 c.c.,
or less, if a strong extract is in use, is in-
jected into the skin of the patient’s arm, form-
ing a small wheal. If the reaction is positive,
as judged by the growth in size, or definite
irregularity of the wheal, with redness of the
surrounding skin, there are 2 plans of action
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
689
to be pursued : First, is the removal of as
much dust as possible from the household by
means of frequent vacuum cleaning, the
avoidance of large areas of carpet, upholstery,
and hangings and the use of waxed wood or
linoleum doors wherever possible. The prob-
lem of the contents of the patient’s mattress
and pillow must be attacked in a similar man-
ner, or they must be changed to other sub-
stances such as Kapok, cotton floss, or silk
floss, depending on the substances to which
the patient is sensitive. Much can be done
along these lines, but it is usually best, when
possible, to attempt reducing the patient’s
hypersensitiveness, if this is present, by in-
jections of the extract. The dosage must de-
pend entirely on the degree of hypersensitive-
ness of the patient. Since some patients are
very sensitive, it is sometimes necessary to
dilute the dust extract before attempting treat-
ment. In general, doses which cause anything
more than a slight local reaction should be
avoided, the amount being gradually increased
and the treatment continued over a long
period of time, months at least. It is unde-
sirable to use a dose which produces an al-
lergic reaction such as a marked aggravation of
the symptom, or local or general hives. Some
of the best results seen are in patients who
have taken the dust extract in gradually in-
creasing doses for a year or more. Usually
not more than 0.7 or 0.8 c.c. is given in 1 in-
jection because of the larger local reactions
caused by the larger amounts injected.
This outline of procedure is described as a
general measure of diagnosis where we sus-
pect hypersensitiveness to an outside factor,
which may be in the house. If we are able
to obtain a definitely positive skin test to some
specific substance, such as horse dander or
cat hair, the procedure is simpler, and it is just
in these cases that the dramatic results may
occur. We find, however, that all cases which
give a definite skin reaction to one specific
outside factor, such as horse dander, do not
lose their symptom after treatment with the
extract of this substance. Some of them con-
tinue with the same symptoms and the same
periodicitv as before treatment. These are
cases which should, of course, be investigated
as to other causes, as completely as possible.
The test to the dust of the patient’s house is
a distinct help.
Characteristics of hy persensitiveness lo out-
side factors. In looking over some of the
cases of asthma which we have seen, we are
first struck by the comparative rarity of the
dramatic kind of case that we would like to
have ; the case where finding and removing
an outside cause is followed by disappearance
of the symptom. This type of case may be
called the true or uncomplicated allergic type,
where the outside factor is the exciting cause.
We feel that it is characterized by a positive
family history; relatively early onset; definite
relation between the symptom and some out-
side factor, resulting in a realization on the
part of the patient of certain circumstances of
time or place which are associated with his
attacks; the presence of some other form of
clinical allergy such as hay-fever, or eczema
during early life, or possibly hives ; the dem-
onstration of positive skin tests to an out-
side factor, and the presence usually of a high
degree of eosinophilia in blood or sputum or
both.
Beside these 6 primary factors we may note
for this rare type of case the usual aggrava-
tion of symptoms by the summer season and
the absence of definite evidences of infection.
When we see a case with all or even most of
these features, we feel that we have one of
the true uncomplicated allergic types, in which
an outside factor or factors are probably the
true and only exciting cause. If the skin
tests happen to be negative in such a case, we
are likely to think that we have failed to test
with the right substance. In such a case we
will continue tests and treatment until we
have either located the cause or have tried
all the possibilities within our grasp.
Characteristics of hypersensitiveness to the
bacterial factor. It is more common that the
case in question shows some of the features
above described, but also some of those about
to be listed : relatively late onset ; or an onset
with immediately preceding infection ; no
definite relation observable in the history be-
tween symptoms and an outside dust factor ;
no positive skin tests ; the presence of poly-
690
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
morphonuclear neutrophiles, together with the
eosinophile cells in the spirals and perles of
the washed sputum. This type frequently is
worse in winter and shows evidence of in-
fection of the respiratory tract on physical
and roentgen ray examination. In addition,
the sputum more often shows a nearly pure
culture of one organism, which is not. how-
ever. usually constant.
If the case in question shows practically
all these features, we consider the bacterial
factor as probably the important element, at
least the effective exciting cause. It is of
course difficult to exclude an underlying al-
lergic factor. It is more usual, however, to
find a mixture of both types. Whether the
injury caused by the outside factors, such as
the various specific exciting causes, renders
the mucous membranes more susceptible to
infection than the normal, or whether a com-
mon predisposing factor leads to both types
of injury, bacterial and nonbacterial, the im-
portance to us of this frequent mixed tvpe
of case is obvious. We must attempt to con-
trol or at least counteract the effect of the
bacteria within as well as the external dust.
Evidence of bacterial infection in asthma.
To counteract such infection, we first need
an understanding of what it is and how it
works. From such information as can be ob-
tained from histories, bronchial infection is
connected with the onset in many cases. We
may neglect the very frequent finding of
“subject to colds” as vague and misleading,
on account of the marked resemblance be-
tween the symptoms of hay-fever and the
first days of the common cold — a resemblance
which possibly may he worked both ways by
speculating on the role of allergy in the cold
— but we cannot pass over the impressive
number of histories which assert that the first
symptom followed influenza, grippe, bron-
chitis. or whooping-cough, as well as the many
cases which report a preceding pneumonia not
necessarily directly connected with the onset.
On physical examination many cases of
more than a few years’ standing do show evi-
dence of focal infection of teeth, sinuses or
tonsils, as well as the chest changes known as
chronic pulmonary emphysema. From x-ray
evidence a great majority show bronchitis,
and especially of the basal type often suggest-
ing mild bronchiectasis, and a good many
show signs of pleurisy more often at the
liases. The sputum commonly corroborates
the other findings by showing in a majority
of our cases of asthma more or less admix-
ture of polymorphonuclear cells with the
eosinophiles which make up the spirals and
perles of Laennec supposedly formed in the
finer bronchioles. Likewise, sputum culture,
though less striking evidence, frequently
yields a nearly pure culture of one organism,
such as a streptococcus of the green type, or
one of the mildly hemolytic type, a pneu-
mococcus, influenza bacillus, hemolytic staph-
ylococcus, or a bacillus of the Friedlan-
der group. When a culture taken in the
way to be described shows a predominance of
Micrococcus catarrhalis, with a few green
streptococci or diphtheroid bacilli, the picture
does not necessarily suggest an active bac-
terial cause at work in the bronchial tree.
Naturally, cases in which the same organism
is repeatedly found, and constantly, are not
common, but they are found, and we feel very
definite about them, especially when ap-
parently the same organism is isolated over a
period of years.
\\ hatever is the relation of the bacterial
to the allergic factor, in most cases of asthma
it is necessary to consider both. Whereas the
factor of allergy to outside causes certainly
shows spontaneous improvement in many
cases, such as the children who outgrow their
idiosyncrasies to food, the bacterial factor
tends to progress and produce more injury.
We may assume that whatever direct harm
the outside factors do to the hypersensitive
mucous membranes, it is far less than that
done by bacterial agents. Although their work
in these cases is usually slow, they apparently
no less certainly on that account may cause
crippling of the chest over a period of years,
and the final result may he permanent damage
and disability, due to the condition of the
chest which we call emphysema and chronic
bronchitis. It is. therefore, important to
reckon with the bacterial factor, and the fol-
lowing measures are available.
Measures directed against bacterial in-
Sept.. 1031
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
691
fection in asthma. First, general hygiene,
sunlight and the avoidance of fatigue and
chilling, in order to prevent advance of the
chronic infection. Second, adequate nutrition,
including the use of glucose in thin subjects
and during acute symptoms, where so much
muscle work is done. Third, the removal of
focal infection, according to a definite pro-
gram based on the physical condition of the
patient. That is to say, that no general rule
can be applied to all cases regarding the elimi-
nation of focal infection. Experience must
guide. Fourth, the use of vaccines.
Concerning vaccines, we feel that it is best
to use autogenous vaccines made from the
patient’s sputum after examination of several
samples. Where expectoration is only peri-
odic, the patient must be given a sterile bottle,
the specimen to be returned to the laboratory
as soon as possible following the period of ex-
pectoration. Where there is a recurrence of
subacute or acute infection, the sample should
be taken just after the period of aggravation
of symptoms, if possible.
Obtaining the organism and the prelimin-
ary skin test. It is important to direct the
patient to avoid excess of saliva, and to bring
the specimen to the laboratory, or send it in,
within 1-2 hours after its production. The
organisms are best grown by spreading the
smaller spirals or perles of Laennec, washed
tree from surrounding mucus, on the surface
of blood plates. The vaccine is made when
possible from the first growth, where pre-
dominance of a single type of organism or a
similar mixture of organisms has been found
reasonably constant. It is best to make the
vaccine relatively dilute, about 200 million
per c.c. in order that the first dose may
be very small. The first dose (0.05 c.c.)
is injected into the skin in order to observe
whether the patient’s skin will show any un-
usual susceptibility to the organism or or-
ganisms in the vaccine. This is usually evi-
denced by redness or a lump at the site of
injection within 1 or 2 days thereafter. In
case of a positive test, start with small doses
and raise the dose cautiously. Some, though
not many, asthma patients do give local, gen-
eral. and focal reactions to their autogenous
vaccines, especially where focal infection ex-
ists. Symptoms of the reaction are similar
to a mild “grippe” or a temporary increase in
asthmatic symptoms, usually followed by in-
creased cough and expectoration and more or
less improvement in symptoms for a time.
As with dust injections, the aim is to give
enough at a dose to cause a mild local reaction
in the arm, and to continue this mild local re-
action with each dose. If no local reaction is
shown, then, we increase the dose gradually,
about 0.1 c.c. each time, with an interval as
short as twice weekly at first until the pa-
tient has shown a mild local reaction, or the
dose stands at about 1 c.c. We at times can-
not give as much as 1 c.c. of an autogenous
vaccine without marked local, or some gen-
eral, reaction. As the dose increases the in-
terval is lengthened, the ideal being to afford
a short interval between duration of the suc-
cessive local reactions. When the vaccine is
made from an almost pure culture of pneu-
mococcus or green streptococcus, or Fried-
lander bacillus, we persist with treatment, for
it is in those cases that we have seen the best
results. If the vaccine used causes no local
reaction on arriving at high dosage, and there
is no focal reaction or improvement in symp-
tom following the doses, further cultures of
the sputum should be made. Different organ-
isms may be discovered, particularly if taken
following or during more acute symptoms. If
stock vaccines are found to give local re-
actions in or under the skin in small or mod-
erate dosage, corresponding roughly to the
autogenous or within 10% of the amount, this
vaccine may be used without or with auto-
genous vaccine (in separate arms).
In conclusion, treatment of the average
asthma case is not a simple matter, on account
of the multitude of causes and presence of in-
fection. Both factors must be looked for,
and an attempt at control of both is usually
necessary. Injections should usually be con-
tinued with short intervals between the per-
iods of treatment. Occasionally the removal
of a single outside factor or focus of infection
is sufficient. Improvement from the con-
tinuous measures is slow, and marked by set-
backs. While good results require time and
692
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1031
continuous control, the results sometimes ob-
tainable make somewhat tedious methods
worth while. The methods used are called
treatment, but are equally an attempt at pre-
vention.
ASTHMA FROM THE STANDPONT OF
THE RHINOLOGIST*
Lyndon A. Peer, M.D.,
Newark, N. J.
The rhinologist in contact with asthma
cases is impressed by the great frequency of
infection in the upper respiratory tract. In
our experience 2/3 of asthmatics have had
some form of infection in the sinuses, tonsils,
teeth, or bronchial tubes. Opinions differ as
to the importance of these infections in caus-
ing asthma. Since Voltoline, in 1880, report-
ed a cure of asthma following the removal of
a nasal polyp, the literature on this subject
has contained many articles by many authors,
some of whom are enthusiastic about the re-
sults of local treatment while others believe
that in spite of procedures both simple and
radical the disease progresses without change.
Thus, we have 2 schools : one holding that the
removal of infective foci gives no relief aside
from promoting the general health of the
patient ; the other believing that many cases
of asthma with foci of infection are cured
when such foci are removed.
We believe that importance of the infective
element varies with each individual patient.
In some asthmatics removal of infected ton-
sils or teeth will be followed by improvement
in general health, but the asthma remains the
same. Another patient, following an ethmoid
operation, may be greatly improved or, less
frequently, cured of asthmatic attacks.
Mechanism of infective foci in causing
asthma. There are 2 theories; (1) Reflex
theory; (2) absorption of bacterial protein.
Keflex theory. Various authors, particularly
Sluder, have considered that bronchial spasm
*(Read before the Morris County Medical So-
ciety, March 12, 1931, as part of a symposium on
asthma.)
was merely a reflex effect of some local stimu-
lus in the upper air passages transmitted
through the nasal ganglia to the sympathetic
trunk in the neck or the vagus nerve. Phillips
and Scott, in a recent admirable review of sur-
gical procedures used for relief of asthma,
declare that there is a predominance of opin-
ion in favor of the vagus being the main
bronchiomotor nerve ; but there is also ample
evidence that there are some bronchio-con-
strictor fibers in the sympathetic. Experi-
mentally, stimulation of the sympathetic or of
the vagus will produce an asthmatic attack —
presumably due to constriction of the bron-
chial musculature.
Absorption of bacterial protein. Protein
from the dead bodies of the bacteria or their
toxins ma}' act in the same way as any foreign
protein in causing asthmatic attacks. An in-
fection may serve as the incitant to an asth-
matic attack in an “allergic individual”. It is
possible that patients who are not “allergic”
do not develop asthma from infections. This
explains how an allergic individual develop-
ing a sinus infection begins for the first time
in his life to have asthma. When the infec-
tion is removed or becomes quiescent, the
asthma improves or disappears until a re-
crudescence occurs to again set off asthma at-
tacks. Hence, a fundamental conception is
that the individual is allergic to begin with
but requires some stimulus to initiate an at-
tack. This stimulus may be pollen, food, bac-
terial protein, or a nerve impulse from an in-
fection in the mucous membrane of the upper
respiratory tract.
Diagnosis. The history is very important
in roughly grouping the infective and non-
infective cases. An all-the-year asthma which
does not respond to changes in diet, nor give
positive skin tests to the various foreign pro-
teins, is apt to have a bacteria factor, also,
asthma which persists for 5 years has an
added infective element which may become
permanent.
Bronchoscopy should be considered for diag-
nostic use in every case of asthma which does
not show protein sensitization or some obvious
infection in the sinuses. Dr. Jackson very
aptly has said “all is not asthma that wheezes”.
Many cases diagnosed as asthma have been
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
found to be due to benign or malignant neo-
plasms. stenosis of bronchial tubes, or foreign
bodies. When these are effectually treated
the supposed asthma disappears. Particularly
in a child, an enlarged thymus or the presence
of a foreign body must be ruled out. Exami-
nation of the nose may reveal a typical poly-
poid ethmoiditis with or without pus, or
simply a somewhat boggy mucous membrane
with hypertrophy of the turbinates. Transil-
lumination of the sinuses is helpful, but the
roentgenography is our best preliminary
means of diagnosis.
When an infected antrum is diagnosed, it
should be punctured, filled with sterile saline,
and the saline withdrawn for microscopic cell
count and culture. In this way we obtain
from the sinus a specimen uncontaminated by
nasal secretions. The antrum is then washed
out and filled with lipiodol, and a second
radiograph taken to demonstrate the condi-
tion of the antral mucous membrane. Usually
we find eosinophiles and neutrophiles in the
infected material withdrawn from the sinus,
and we diagnose an antrum as infected when
polynuclear leukocytes and bacteria are found.
In an allergic patient structural changes in the
mucous membrane, as shown by lipiodol radio-
graph, could be due to repeated edema into
the tissue structure ; polys and bacteria in any
considerable number, however, indicate infec-
tion.
There is a so-called hidden antrum infection
in which the bacteria reside in the subepi-
thelial layer of the mucous membrane, not
producing surface change, but causing struc-
tural changes in the tissue. A single washing
from such an antrum may not grow any bac-
teria or show any polys, but still the infection
may be a causative factor in the asthma.
Where there is disease of the frontal sinuses
a history of intermittent, dull, frontal head-
ache, particularly on bending forward or on
blowing the nose, is usual. There is often
tenderness on pressure at the inner frontal
angle. The headaches sometimes begin after
using the eyes and are mistakenly diagnosed
as eye-strain. Pain behind the eyes, at the
top of the head, or in occipital region, is sug-
gestive of sphenoid disease. The sphenoid
sinuses may be filled with sterile saline and
693
the saline withdrawn for examination through
a canula inserted in the osteum. Lipiodol can
then be injected and a radiograph taken to
determine the condition of the mucous mem-
brane.
Ethmoid disease usually shows up well in
an x-ray picture. The presence of polyps is
always strongly suggestive of ethmoid in-
volvement. Generally speaking, pus seen in
the anterior portion of the nose is coming
from the frontals, anterior ethmoids, or an-
trum. When found postnasally it comes from
the posterior ethmoids or the sphenoid. Very
frequently in chronic infections no discharge
will be seen in the nose or pharynx, nor will
any be found in the sinuses themselves, and
this dry state of sinus infection is called
hyperplastic sinusitis, and includes the hidden
antrum already described. The bacteria exist
in the subepithelial layers of the mucous mem-
brane causing a thickening of this structure
but not in any surface exudation. The wash-
ings from such an antrum or sphenoid are
often entirely clear and yield no growth when
cultured. Absorption of bacterial protein or
toxin from the organisms beneath the epi-
thelium, however, may be a factor in causing
asthma. Hence, one cannot conclude that a
sinus is uninfected merely because a surface
exudation does not exist. The presence of
bacteria in the mucous membrane of hyper-
plastic cases has been beautifully demon-
strated by Kistner. Both the exudative and
hyperplastic stages must be regarded as
simply differing phases of infection.
Infected tonsils are diagnosed by inspection
and palpation ; infected teeth and mastoids by
physical and x-ray examinations.
Pathology of nose and sinuses in asthma.
In early stages, the mucous membrane of the
nose and sinuses is swollen and the subepi-
thelial tissues show edema and infiltration
with eosinophiles. In the chronic cases the
epithelial layer becomes thicker than normal,
loses its cilia, and assumes the characteristics
of stratified epithelium. The glands atrophy
from pressure, and may be seen as cysts
where their ducts have become occluded.
There is considerable edema and connective
tissue proliferation with infiltration of round
cells and eosinophiles. Polyps form from sag-
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
ging of the edematous mucous membrane.
\\ here infection is present, polys and bac-
teria are added to this picture.
7 reatment. In our experience removal of
infected tonsils and teeth often improves the
general condition of the individual, but it does
not affect the asthma. Disease of the sinus,
however, when cured, may lead to improve-
ment. or. in rarer cases, to an actual clinical
cure of the asthma. The best policy is always
to proceed slowly, and simple shrinkage to
promote drainage of the infected sinus is
first used. If polyps or an obstructive middle
turbinate hinder this drainage, they are re-
moved. An infected antrum or sphenoid is
irrigated repeatedly until the washings are
clear and the cultures negative. Bacterial vac-
cine is made from the sinus culture, and ad-
ministered in conjunction with the local treat-
ment. Infected tonsils or teeth are removed
when they appear to he factors in causing a
run-down condition. Asthma of long stand-
ing may not yield readily to such treatment
because of infection in the bronchial mucous
membrane. Such cases should, in addition, be
treated by bronchoscopic methods which re-
move the irritating secretion, clean out the in-
fected contents of bronchiectatic cavities, and
provide locally for the infected mucous mem-
brane. Most asthma patients of the infective
type will be improved to some degree by the
above treatment, and a few, particularly early
cases, will be cured, while a small number will
remain without improvement.
Where conservative treatment has been
without avail, we advocate removal of the in-
fected mucous membrane of the sinuses. Eth-
moids and antrums usually yield the best re-
sults following radical operation ; sphenoids
and f rentals the poorest. Local treatment,
with removal of infected tonsils or teeth, will
often make the patient a better operative risk
for the radical sinus operations where these
are found necessary. A combination of con-
servative and radical measures will give a
larger total number of improved cases and
cures than either of these methods alone.
In conclusion, the fact must be emphasized
that asthma cannot often be improved and is
far less frequently cured by any one panacea.
The rhinologist who examines a patient, dis-
covers an infected sinus, and exclaims that he
will cure the asthma by operating on the sinus
is unduly optimistic, to say the least. The
combined efforts of the internist, allergist, and
rhinologist, will effect improvement in a large
number of asthma patients ; but no improve-
ment in a small proportion of the total.
CHILD HYGIENE
Julius Levy, M.D.,
Newark, N. J.
Child hygiene should not he confused with
child welfare or the medical care of sick chil-
dren. Perhaps the most fitting definition is
“that phase of hygiene which has for its pur-
pose to make growth more perfect, decay less
rapid, life more vigorous, and death more re-
mote". We have come to include in it many ac-
tivities, but it will be found that only those
phases which can he influenced by education
are considered the immediate concern of child
hygiene as we have interpreted it. It is felt that
all the time and energy and money appro-
priated for these purposes should be devoted
purely for prevention.
The functions and activities of a well-or-
ganized child hygiene bureau should include:
( 1 ) Those phases of public health which
deal with the reduction of maternal mor-
tality. We would include prenatal advice to
mothers by nurses, prenatal care by physicians
in private practice and through prenatal
clinics, medical examinations by physicians,
irrespective of the attendant at labor, careful
investigation of puerperal deaths, particularlv
those attended by mid wives, and supervision
of mid wives.
(2) Those functions which deal with the
reduction of infant mortality. We would re-
peat the importance of prenatal care of moth-
ers and proper obstetric care at time of de-
livery, the instruction of midwives in infant
hygiene, instruction of mothers in infant care
with special emphasis on maternal nursing,
competent supervision of young infants
through private supervision or Baby-Keep-
Sept.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
695
Well Stations, and instruction to mothers in
the homes by visits of competent public health
nurses.
(3) The proper care of children of pre-
school age. This is to be obtained by periodic
examination, by instruction to mothers in the
importance of prompt and early medical at-
tendance for all illnesses and noticeable de-
fects, by a proper follow-up to see that de-
formities and defects discovered are corrected
before children come to school, and by the
immunization of children against small-pox
'and diphtheria about the age of 1 year. We
would point out here that nurses who suc-
cessfully acquire the mental hygiene outlook
can render great service in helping mothers to
adjust themselves and their children. Further-
more, since the importance of .the relationship
of Vitamin D to the structure of the teeth has
been pointed out, and since it has been found
that carious teeth are probably the result of
defective structure, it becomes clear that the
most effective dental prophylaxis will be
found in effective child hygiene. Dental clinics
for prophylactic purposes should be more
largely restricted to the detection of fissures
and proper care.
(4) Continuation of supervision of chil-
dren of school age. For public health super-
vision it is important, in addition to competent
medical examinations, to have nurses visit the
homes to instruct mothers in the importance
of continuing the proper care, feeding, and
management of school children, as well as
young infants; and to impress upon them the
importance of having defects and deformities
promptly corrected. In this period it becomes
particularly important to reduce contagious
diseases and to instruct mothers in the im-
portance of giving proper care and rest to
children with so-called minor contagious dis-
eases. If the plan of continuous child hy-
giene supervision is followed, as was suggest-
ed, it becomes necessary only to continue
health habits which have already been estab-
lished.
(5) Prevention of blindness. It has long
been known that a considerable percentage of
blindness is a result of ophthalmia neonatorum
especially that of gonorrheal origin. The use
of 1% silver nitrate solution in the eyes of
new-born babies is practically a positive pre-
ventive. This is being done in almost all
cases delivered by midwives. The child hy-
giene nurses are especially valuable in this
phase of public health work, since by early
visits they are able to note inflamed eyes, to
arrange for prompt and accurate diagnosis,
and prompt and thorough follow-up and treat-
ment.
(6) Illegitimate infants. Infants of un-
married mothers present a special problem.
There are reported about 1200 each year in
the state of New Jersey. It is reasonable to
believe that many are unreported. Proper
plans of cooperation among hospitals where
these mothers are delivered, social agencies,
and public health departments, have done much
to reduce the mortality among illegitimate in-
fants and to obtain proper care for their
mothers. In Newark, the Convalescent Home
for Nursing Mothers has been particularly
helpful.
(7) P> oar ding homes. The licensing of per-
sons boarding infants has practically eliminat-
ed “baby farms" from the state of New Jer-
sey. It has made available safe homes for
those who need to be boarded out and has,
furthermore, reduced considerably the num-
ber of children who are unnecessarily boarded
out. This system has also reduced the num-
ber of children boarded in New Jersey from
outside the state.
(8) Cooperation with other agencies,
bureaus, and departments. The child hygiene
nurse, through her intimate knowledge of
thousands of families in which there are
young infants, has been very effective in per-
fecting birth registration ; assisting in the con-
trol of contagious diseases ; improving sanita-
tion and housing conditions ; reporting and
following up venereal diseases and tuber-
culosis ; bringing to the attention of social
agencies many family welfare problems which
bear heavily upon children ; and in discover-
ing and reporting cripples and obtaining
proper care for them.
What is the status of infant mortality in
New Jersey? The infant mortality rate in
1918 was 112. In 1930, it was 55. Whereas
in 1918 there were many counties with infant
mortality rates above 100 and only a few
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
with infant mortality rates below 80, by 1925
there were no counties with infant mortality
rates above 100 and only 15 with infant mor-
tality rates above 80. In 1929, all the counties
presented infant mortality rates below 80 and
6 presented infant mortality rates below 60.
One way of gauging what has been accom-
plished in New Jersey is to note the number
of child hygiene nurses under state super-
vision alone. There are today some 135
nurses in some 500 communities; this aside
from nurses under the child hygiene bureaus
in the larger cities.
The infant mortality rate in Newark has
shown an even greater decline. This rate in
1930 was 52.1, the lowest that has ever been
reported for the city and one of the lowest in
the country. It is interesting to observe that
the lowest infant mortality rate has occurred
in the year of the greatest economic distress.
This is merely a repetition of a previous ob-
servation of the fact that the lowest infant
mortality rate in Paris occurred in the Siege
of 1870; and one of the lowest infant mor-
tality rates of the cotton manufacturing cities
of England occurred during the Civil War,
when women were unable to obtain employ-
ment on account of the inability to obtain raw
cotton from the United States. At the same
time, we would point out that there has been
practically no reduction in the mortality of
the first month of life. The deaths in the first
month now represent of all the deaths
which occur in the first year ; that is, as many
babies die in the first month as die in the suc-
ceeding 1 1 months. When we analyze the
deaths in the first month we are impressed by
the fact that practically of them occur dur-
ing the first day, which shows clearly the re-
lationship between early mortality and pre-
natal and obstetric care.
Our studies of maternal mortality have
brought out many important and interesting
facts. 1 here has been practically no reduc-
tion in maternal mortality in the past 10
years. Secondly, about 1/3 of the deaths of
mothers is associated with the first 6 months
of pregnancy. In this sense they should not
be looked upon as obstetric deaths but merely,
deaths associated with the state of pregnancy.
1 here has been a reduction in maternal mor-
tality associated with the last 3 months of
pregnancy. It is, however, a matter of grave
concern that the maternal mortality of this
nation is higher than that of a great many
foreign countries and that, even if we sub-
tract the mortality associated with the first 6
months of pregnancy, our mortality is still
higher than that of the Netherlands, Norway,
Sweden, and Italy.
While there has been this reduction in in-
fant mortality, it is worth while to point out
that this reduction has not been uniform. In
the city of Newark, the mortality rate varies
considerably in various wards, some presenting
rates as high as those which were reported for
that city 15 years ago. This is particularly
true in the wards which present a large color-
ed population. When we examine the causes
for this reduction in infant mortality, con-
siderable information is obtained by observing
the mortality by seasons. Whereas in 1914-15
there was a high peak of mortality in the
months of July and August, today there is a
valley in the mortality graph for those months.
In short, the safest period of the year for an
infant under 1 year of age in Newark is in
the month of July. You will be prepared, then,
for the observation that the greatest reduction
has occurred in the diarrheal diseases. If we
were to compare the specific death rate for
infants in 1929-30 with that of 1920-21, we
would find that the rate is only about 1/3 of
what it was 10 years ago.
I here has been a reduction in the deaths
under 1 year from whooping-cough and
measles and, likewise, meningitis. We believe
that this is a concomitant result of the general
improvement in the care, management, early
diagnosis, and treatment of infants.
Now, as we have reviewed the saving of
life which has come from practically the elim-
ination of diarrheal diseases of infancy and
from the concomitant result observed in
whooping-cough and measles, we are the more
impressed by the fact that in the past 10 years
there has been practically no reduction in the
deaths in the first year of life associated with
early infancy and with bronchitis and pneu-
monia. It is clear that further progress in
the reduction of infant mortality will have to
come from the development of methods which
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
697
will prevent maternal mortality, premature
birth, cerebral hemorrhage, and then the more
effective control of respiratory diseases.
REFRACTION AND HEALTH*
Pierce Shope, M.D.,
Camden, N. J.
Dr. George E. de Schweinitz, in an address
before the Medical and Chirurgical Faculty
of Maryland, April 26, 1900, said: “It is un-
questionably true that fully 75% of ocular
disorders depend on anomalies of the refrac-
tion, accommodation, or muscle balance of the
eyes. Correction of such faults is followed
by the greatest good to the eye and to the
general organism in which the strain has been
interpreted by symptoms not necessarily sug-
gestive of their origin. When one comes to
think about them, these symptoms stretch out
into an extraordinary train, but we have
ceased to wonder, and as a matter of course
investigate, or cause to be investigated, the
eyes whenever searching for the etiology of
headache of all kinds, migraine, vertigo, nau-
sea, pseudo and habit chorea, neurasthenia,
and other disease-phenomena of similar mani-
festation. We have learned that many so-
called gastric troubles — tachycardia, flatulent
and other types of dyspepsia, indigestions,
night terrors, especially as they occur in chil-
dren— may have a like origin, and we have
found out that pains strangely and persistent-
ly situated in the nape of the neck, between
and under the shoulder blades, at the end of
the spine and deep in the mastoid, may owe
their origin to the same cause. These facts
are widely — I was about to say almost uni-
versally— known, although, curiously enough,
many of the most important of them find no
place in the most-used text-books on general
medicine.”
That eye-strain may produce symptoms ap-
parently unrelated to the eyes but seemingly
arising from disease or dysfunction of some
*(An address given before the Camden County
Medical Society, April 7, 1931, as part of a sym-
posium upon ophthalmology.)
distant organ, has been known for more than
50 years. Silas Weir Mitchell, in 1874, wrote
a paper on the relation of nervous disorders
to eye-strain and presented a series of cases
in which such disorders were corrected by the
wearing of glasses. In 1876, another paper
appeared from the same pen, upon the rela-
tion of headaches to eve-strain. These 2 mas-
terpieces did more to awaken the ophthalmol-
ogist to the remote symptoms produced by
refractive errors, and to the need for accurate
refraction, than perhaps any others.
George M. Gould, 30 years ago, wrote
voluminously on this subject. He was con-
sidered an extremist because of the large
number of diseases and symptoms he attribut-
ed to eye-strain. Today, ophthalmologists
know that while some of his statements have
been shown to be exaggerations, a consider-
able portion of his assertions were true, and
for the relief of those symptoms Gould em-
phasized the fact that only an accurate re-
fraction examination is of any value. Today
we see a large percentage of patients referred
for relief of remote symptoms. To discuss all
of them would require more time than we
have allotted to us. A few will suffice.
Headaches, especially frontal; although
temporal, occipital, and parietal headaches are
common ; hemicrania ; headaches associated
with nausea and vomiting ; carsickness ; pan-
orama headaches, the headache acquired at
the movies, a ball game, or in crowds any-
where ; vertigo ; headtilting and the compen-
satory scoliosis that often accompanies it ;
tachycardia ; anorexia ; indigestion ; flatu-
lence ; hyperacidity ; constipation ; pains most
anywhere ; neuralgia ; paresthesias ; tics ; neu-
rasthenia ; nervousness ; insomnia ; sleepiness ;
and a host of other complaints are frequently
associated with eye-strain.
Besides these reflex symptoms, the com-
mon local symptoms are burning and itching
of the eyes; heavy lids; blepharitis; conjunc-
tival hyperemia ; blurred vision ; poor near or
distant vision; photophobia; and spots before
the eyes.
Of course, all these symptoms so commonly
associated with refractive errors may occur
with disorders of other organs. Sinusitis, nasal
obstruction, gastric and hepatic disorders,
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept.. 1931
constipation, and prostatic disease, commonly
give rise to hyperemia of the conjunctiva,
pain in the eyes, vertigo, nausea and vomiting.
Chronic otitis media is a common source of
headache, vertigo, nausea and vomiting. Pel-
vic conditions, diseases of the brain and cen-
tral nervous system, in fact almost any chronic
disorder may produce symptoms suggestive
of eye-strain.
Hence, in refraction, the eye physician is
first faced by the problem of determining if
the symptoms complained of are due to an
ocular defect. Second, he determines if the
symptoms arise from disease of the eyes
rather than from a refractive error. Third,
if no ocular disease exists, the refractive er-
ror is estimated and accurately corrected.
Last, maladjustments of the ocular muscles
are investigated and cared for.
Refraction can be defined as the determina-
tion of errors of the focus of the eye. But it
is desirable at this time to deal with refrac-
tion in a broader sense. In the beginning a
careful history should be taken. The vision of
each eye for near and far is noted. The bal-
ance of the extra-ocular muscles, with the eyes
at functional rest, is determined. Prism-duc-
tion tests are made to determine the strength
of various muscle groups. Each eye is then
studied externally. That is followed by an
ophthalmoscopic examination. In other words,
no case is assumed to be a “refraction case”
until all other ocular possibilities are ruled
out. The search for ocular pathology is the
first aim of the examination. Very frequently,
some abnormality is found, which abnormality
may be purely ocular or may be a manifesta-
tion of some general disease or of disease in
some remote part of the body. Here again,
the eye physician is of much service to the
patient and the family doctor. Frequently,
evidences of diabetes, nephritis, tabes dorsalis,
brain tumor, syphilis, tuberculosis, nasal ac-
cessory sinus disease, focal infection, and
many other conditions, are found in the eye
before general signs and symptoms are mani-
fest.
I he eye is a part of the body. It cannot be
divorced therefrom without loss of function.
It must be so considered. Only a physician
can be competent to recognize all the possi-
bilities that this relationship implies. Only
he is sufficiently interested to feret out pos-
sible disease. Only he is permitted to treat
disease when found. The essential thing, then,
is neither the prescribing nor the fitting of
glasses but proper diagnosis of the condition
present. After the diagnosis of refractive
error is made, the ophthalmologist proceeds
to the refraction proper.
In persons under presbyopic age it is cus-
tomary to use “drops” of some kind. The
purpose of these “drops" is to quiet accommo-
dation. It is hardly necessary to explain the
value of cycloplegics to physicians. I might,
however, recall to your minds that the process
of accommodation is one not well controlled
by the will. Accommodation is constantly
changing. To estimate refraction of an eye
with accommodation present is to attempt
to measure a constantly altering quantity. It
is just as ridiculous as weighing a person who
is jumping up and down upon a scale.
A correction of refractive error, to he of
any great value, must be exact. An approxi-
mation of this error is not enough, if the symp-
toms are to be relieved. Such correction should
be the same as the error, to within l/§ of a
diopter.
Retinoscopy, an objective method of de-
termining the refraction, can be done with
great precision when cycloplegics are used.
I hen the subjective method need be used only
as a check upon the observations of the physi-
cian. As with all methods used by science,
the objective method is more reliable and more
exact than the subjective. Of course, ret-
inoscopy can be done without cycloplegia.
but no accurate estimation of refraction can
thus be made. A band of 1 to 3 diopters is
found at every point in which the shadow test
may be “with" one time and “against” the
next time. Dynamic retinoscopy, as this is
called in contradistinction to static retinoscopy
as done under cycloplegia, is a snare and a
delusion. It will not even diagnose between
hyperopia and myopia unless the error is high.
I hen. there is another reason for using
drops’ ; and that is for dilatation of the
pupil so that a thorough examination of the
interior of the eye can be made. No one can
ascertain with any exactitude the condition of
Sept.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
699
the periphery of the lens through a small
pupil, and that is where senile cataract usually
begins. Nor can the vitreous be well inspect-
ed for opacities. The macula frequently is
difficult to see through a small pupil, and
there, again, pathology is frequently found.
The periphery of the retina cannot be ob-
served through a 2.5 mm. pupil, and anterior
chorioiditis is no rarity. Certainly, no one can
say he has examined an eye until he has
studied it ophthalmoscopically through a di-
lated pupil. Hence, in patients long past the
age where accommodation is active, pupils are
dilated unless signs suggestive of glaucoma
are present. In older patients, however, no
cycloplegic, such as atropin, scopolamin or
homatropin is used ; instead, cocain, euco-
tropin, ephedrin or some other weak mydriatic
is instilled. Following the fundus examina-
tion in these older people, a retinoscopy may
be made through the dilated pupil. Personally,
I do this routinely. When all examinations
are completed that require a dilated pupil, a
miotic, such as pilocarpin or eserin, may be in-
stilled, which in a short time overcomes the
pupillary dilatation.
Another important thing that should be
mentioned about the use of cycloplegia is
that the eye is put at rest for a period of time
depending upon the drug used. This permits
the retina, chorioid and ciliary body to re-
cover from the irritation and congestion inci-
dent to eye-strain.
As for danger from the use of cycloplegics,
one can but point to statistics from large eye
clinics, where, thousands of cases are refracted
yearly and where untoward effects of any
kind are of exceeding rarity. At the Wills
Eye Hospital, a report was given about 1
vear ago of all cases refracted within 3 years
preceding the report, and in 30,000 refraction
cases no complication of any consequence was
noted.
After the drops have worn off, another ex-
amination is made; the postcycloplegic exam-
ination. In hypermetropic patients the amount
of plus sphere that they will accept is de-
termined. Myopic patients are given the exact
correction found under cycloplegia unless
such correction is very high, when a reduction
may be made. The most important part of
the postcycloplegic examination, however, is
determination of the muscle balance while
wearing the new correction. The latent ten-
dencies to deviation of the eyes from the
parallel, the heterophoria, should never be
neglected. The tendency for one eye to be-
higher than the other, hyperphoria, if of suffi-
cient amount, should be corrected with at
prism ground into the glasses. Tendency for
the eyes to turn out, exophoria, is treated by
exercises and reduction of convex sphere.
Frequently, exophoria and convergence in-
sufficiency are the result of ethmoid disease,
and treatment of the latter condition is re-
quired before any relief can be obtained for
the ocular muscle disturbance. The tendency
of the eyes to turn in, esophoria, is treated
with the stereoscope and giving full convex
spheres. Heterophoria is the frequent cause
of eye-strain and no ocular examination is
complete without investigation of the ocular
muscles. Numerous patients are seen suffei*-
ing with dizziness, nervousness, nausea, indi-
gestion and headache, who are wearing a
proper refraction correction but whose mus-
cular imbalance has been neglected. These
patients can be relieved only by treatment of
the heterophoria.
To summarize :
The purpose of refraction is much broader
than the term implies and is best epitomized
in the phrase, “ocular examination”. The pur-
pose of refraction in this broader sense is to
discover the causes of the symptoms ; first,
whether they are ocular at all, ocular in part,
or ocular entirely; second, whether the symp-
toms arise from some disease of the eyes;
third, to make an exact determination of the
refractive error; fourth, the muscular bal-
ance and abnormal muscular tendencies are
determined and treated.
700
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
SQUINT IN CHILDHOOD AND ITS
EFFECT IN LATER LIFE
Willard G. Mengel, M.D..
- Camden, N. J.
The detection of squint in children at the
earliest age, and the etiologic factors involved,
together with measures taken in correction of
squint and the effect in later life, is briefly the
scope of this paper. The importance of the ex-
competent hands, so as to receive the greatest
benefit during important years of develop-
ment, when the visual elements, fusion facul-
ties, and ocular muscle movement coordina-
tions are being established.
A frequent expression heard from moth-
ers is : “I thought the child would outgrow
the condition.” Sometimes, on advice of anx-
ious relatives and friends, nothing is done,
waiting the time for the child to outgrow the
defect. The eyes may appear straight to
them, but there may be a latent defect giving
Fig. 1. Convergent Strabismus
E. P. Aged 4 years
Right eye convergent. Refractive error— Compound
Hyperopic Astigmatism.
Fig. 2. Convergent Strabismus
E. P. Same as figure 1
Showing correction of convergent right eye with
glasses. Using glasses one year.
animation of children’s eyes, especially during
the pre-school age, should lie emphasized.
Many conditions of children's eyes go un-
recognized until later years, when correction
of the defect becomes more difficult and the
result unsatisfactory. There is no reason for
conditions like congenital cataract, the various
forms of keratitis, phlyctenular conjunctivitis,
blepharitis, and squint, to be present for years,
even until the twenties and thirties, and then
having to be corrected by a spectacular opera-
tion for restoring vision to a person blind
from birth. These conditions should be diag-
nosed between 1 and 5 years of age, if in
rise to severe symptoms of eye-strain. The
result of delay being poor vision in one
eye.
Squint, or strabismus, is a condition in
which the visual lines of the two eyes do not
intersect at the point of fixation, and is mani-
fested by a deviation in, out, up or down, of
the eye. With the advance of our knowledge
in regard to this subject, it has become known
that scarcely one case of squint is like another,
for it is not simply a faulty position of one
eye, but rather the external symptom of one
or another of various disturbances.
Sept., 1 U 3 j
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
701
Fig. 3. Convergent Strabismus
(Esotropia.)
W. P. Aged 4 years
Right eye convergent. Refractive error — Compound
Hyperopic Astigmatism.
Fig. 4. Convergent Strabismus
(Esotropia)
W. P. Same as figure 3
Aged 5 years, right eye convergent.
Fro. 5. Convergent Strabismus
(Esotropia)
W. P. Same as figure 4
Showing improvement with glasses; glasses 3
months; Compound Hyperopic Astigmatism.
702
JOURNAL OF THE MEDICAL
SOCIETY OF NEW JERSEY
Sept., 19.31
In the majority of cases, if one eye fixes
an object with the fovea, the other will do so
too, giving rise to binocular fixation. In fact,
the whole extremely complicated mechanism
of muscles and nerves with which the eyes
are supplied, is designed primarily to accom-
plish this single end; i.e. to so move the eyes
that they shall both he directed accurately to
the object we wish to see, and that each shall
receive the image precisely upon the fovea.
The movements of both eyes are hence al-
Fig. 6. Divergent Strabismus
(Exotropia)
I. M. Aged 6 years
Right eye turns outward; refractive error — Com-
pound Myopic Astigmatism tR), Hyperopic
Astigmatism (L.)
most invariably coordinated so as to secure
binocular fixation under all conditions. When
both eyes fix the same object, they are said
to be straight. This is regarded as the ideal
or natural condition. In other instances both
eyes will look straight at the same object
when both are uncovered, but either eye, as
soon as it is covered, will deviate— turning
out, in, np or down. 1 his is looked on as an
“insufficiency” (heterophoria), which may
give rise to squint, and is indicative of eye-
strain with refractive error. There is a ten-
dency to squint, becoming manifest only on
covering one eye. In the third class of cases,
only one eye is straight (fixes the object) at
a given time, the other deviating even when
both eyes are uncovered. This condition is
squint, strabismus or heterotropia.
Briefly, there are 3 types of squint: first,
convergent squint, when the eye turns in to-
ward the nose — the most common variety ;
second, divergent squint, when the eye turns
Fig. 7. Divergent Strabismus
I. M. Aged 6 years
Same as figure G, right eye turns outward, show-
ing correction with glasses; using glasses
6 months.
outward away from the nose; and third, ver-
tical squint, when the eye turns either up or
down.
Convergent squint, or “cross-eye”, develops
between 1 and 5 years of age in the greater
percentage of cases. First, the eye turns in
toward the nose only at certain times; at
other times the eyes are straight. This is the
forerunner of a constant convergent squint. In
<S0% of cases the squint is monocular from the
first ; while in about 20% sometimes one and
sometimes the other eye turns in, and we have
Fig. 8. Vertical Strabismus
(Left Hypertrophia)
R. F. Aged 11 years
Left eye turns upward. Refractive error — Com-
pound Hyperopic Astigmatism.
perfectly developed; (3) the visual sensation
of the squinting eye is suppressed; (4) its
vision is subnormal; (5) usually the eyes are
hyperopic or have hyperopic astigmatism.
Convergence excess is usually accommoda-
tive; i.e. the child in trying to see well forces
the accommodation, and hence also forces the
convergence, as the two are closely associated.
This is true especially when the child is trying
to overcome a hyperopia or hyperopic astig-
matism, which is almost always present in con-
Fig. 9. Vertical Strabismus
(Left Hypertropia)
R. F. Aged 11 years
Same as figure 8 ; left eye turns upward showing
correction with glasses and prism; glasses
3 V2 years; Compound Hyperopic
Astigmatism.
veloping convergent squint, but it is often too
late. Under no circumstances should a physi-
cian put off the parents of such children, for
the cases of convergent squint that disappear
later with development of the child and its
ocular functions, are rare exceptions. The
physician should send children with commenc-
ing strabismus to the ophthalmologist, that he
may take the initiative, even though they are
only a few months old.
Sept.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
703
vergent squint. The squint is increased as
soon as the child begins to use the eyes for
near work, as a spasmodic convergence takes
place. Little by little the deviation increases
until binocular fixation becomes impossible.
At this stage, suppression of the image of
the squinting eye takes place, with a resulting
failure of visual elements and fusion to de-
velop ; so that the longer the squint has ex-
isted, the less the vision and the more difficult
is development of the fusion faculty. Hence,
it is never too early for treatment of a de-
alternating squint. Statistics show that the
monocular variety begins in about 75% of
cases toward the end of the fourth year, and
that the alternating variety appears rather
earlier in 25% of cases, sometimes as early
as the age of 6 months. It is impossible to
demonstrate by one or by several cases all of
the phenomena we meet with in convergent
squint, but the following cardinal symptoms
are generally to be found, more or less mark-
ed. in every case: (1) The convergence power
is excessive; (2) the power of fusion is im-
704
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
Divergent squint is seen more frequently in
myopia. As accommodation and convergence
are intimately associated, the disuse of one
means disuse of the other. A myope, for ex-
ample, to see objects nearby, needs to use
little or no accommodation ; consequently the
impulse to converge is too weak. Disuse of
convergence allows the eye to deviate out-
ward in high degrees of myopia, gradually
producing divergent squint.
Conditions affecting the vision, such as con-
genital cataract, central chorioiditis, corneal
opacities, and marked myopic astigmatism in-
terfere with fixation, and, as a consequence,
the non-seeing eye deviates outward, produc-
ing divergent squint.
Vertical squint in many instances is caused
by paresis, or at least insufficiency of one of
the elevator or depressor muscles of the eye.
Some cases are spasmodic in origin.
In the treatment of squint, the most im-
portant consideration is the refractive error.
Excessive accommodation should be corrected
in convergent squint, and deficient accommo-
dation in divergent squint, by proper glasses.
The earlier the age this is done, the better
the results, and the more useful the vision in
the squinting eye. Binocular fixation should
be obtained as early as possible to prevent
amblyopia. Congenital cataracts, diseased
conditions and astigmatism should be diag-
nosed at the earliest age and corrected. Mea-
sures to develop fusion and correct the ambly-
opia must be undertaken in connection with
the use of glasses. In former times, the treat-
ment seemed fairly simple to correct the posi-
tion of the squinting eye by operative meas-
ures ; but now, operation is the last resort,
after every other possible method to improve
the condition has failed.
The effect of squint, in later life, is mon-
ocular sight, with greatly reduced vision in
the squinting eye. The visual elements have
not developed, and consequently amblyopia is
marked. The result is the same, practically,
as a one-eyed person ; deficient perception of
depth and absence of stereoscopic vision. The
cosmetic effect is readily appreciated, and
often, for this reason, operation is undertaken,
although in later years improvement in vision
and binocular fixation are not apt to result,
even after operation which corrects deviation
of the squinting eye.
COMMON CONDITIONS IN INDUS-
TRIAL OPHTHALMOLOGY
George J. Dublin, M.D.,
Camden, N. J.
Industrial ophthalmology is really a phase
of general medicine and concerns traumatic
affections, infections and occupational eve
lesions. It is my purpose in this brief paper to
discuss only some of the common conditions
with which we are confronted and to bring
out a few salient factors in the handling of
such cases.
Affections of different parts of the eye give
entirely different symptoms. A careful his-
tory is in every case extremely important for
the correct diagnosis and proper handling of
the case. 1 stress this point because mislead-
ing histories of the accident, as told by the
patient, may not agree with the physical signs
present and will often mask the underlying
condition.
The lids are nature’s first line of defense in
protection against injury of the eye and its
contents. When danger threatens, the lids
involuntarily close and prevent or minimize
the effect of an accident. The injuries com-
mon to this region are wounds (incised, lacer-
ated and contused), burns and retained for-
eign bodies. Treatment is the same as for
any other part of the body and concerns
guarding against infection and care in sutur-
ing to prevent deformity, such as turning in
or out of the lid, with resultant chronic in-
flammation of the eye. Emphysema, if pres-
sent, is usually associated with fracture of the
floor or nasal wall of the orbit. If swelling is
marked, pricking of the tissues to allow es-
cape of air is recommended. If the lacera-
tion is complete, careful inspection of the ex-
ternal coats of the eyeball is necessary, as
further damage may have occurred. If a
hemorrhage of the lid is present, eliminate
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
705
the possibility of a foreign body, by history
and x-rays, if history is suspicious. For the
ordinary hemorrhage or ecchymosis, ice com-
presses applied during the first 24 hours, fol-
lowed by heat, afford the best relief and has-
ten absorption of the blood. Lead water and
laudanum are of some help.
Should the lids fail to prevent entrance of
the foreign body or inflammatory products,
then we have nature’s second line of defense,
before perforation and rupture of the eyeball
can occur; this is the cornea, conjunctiva and
the dense sclera. The most common condition
involving these parts is a conjunctivitis; the
injection may be slight or marked, and pain,
lacrimation and discharge may be mild or
pronounced. Treatment of the conjunctivitis
depends on the cause. If a foreign body is
present, removal of the foreign body, and use
of a simple boric acid wash containing holo-
cain afford relief. In seeking for the foreign
body, both the upper and lower lids should
be examined, as well as the cornea. If no
foreign body is present, and if the main com-
plaint is a scratching sensation, referred to the
upper lid, one must eliminate the possibility
•of an abrasion of the cornea. For detection
of a corneal abrasion a drop of 2% solution
of fluorescin on the cornea will reveal any
denuded corneal epithelium, which will stain
green while normal tissue will remain unstain-
ed. Mercurochrome 2% solution will act the
same way, staining the denuded area a red-
brown.
One drop of an anesthetic, preferably 1%
holocain hydrochloride, and protecting the eye
from light with a gauze dressing, yield al-
most complete relief. Cocain may also be used
in the eye as an anesthetic for relief of pain.
Cocain, although a good anesthetic, has dis-
advantages ; it causes dryness of the cornea
and interferes with the healing process by
cutting off nutrition and causing a desquama-
tion of the epithelium ; it may also increase
tension, and cause an attack of acute glaucoma
in a potential or actual glaucoma case. For
this reason, it is rather dangerous to instil
cocain in the eyes of people beyond the mid-
span of life, without first taking the tension,
either by palpation or with the tenometer, or
•examining the fundus with the ophthalmo-
scope. In an acutely red eye, atropin or
homatropin should be used with care for the
same reason.
The cornea may be involved in various
manners. The most common condition is
presence of a foreign body. Removal of the
foreign body is important because of the pos-
sibility of infection, scarring of the cornea
and ultimate blindness. Detection of ulcer
is possible by staining with fluorescin. The
entire cornea, or a small sector, may be in-
volved as a type of traumatic keratitis. Per-
foration of the cornea may occur and the
damage done depends on the structures in-
jured. Involvement of the lens causes an
opacity (cataract), and there may be an es-
cape of aqueous humor from the anterior
chamber, with incarceration of the iris in the
wound. Perforation may also cause detach-
ment of the retina or of chorioid layers of the
eyeball, or rupture of the chorioid. In these
cases of perforation of the eyeball eliminate
the possibility of an intra-ocular foreign body
by x-rays, and not only avoid loss of the in-
jured eye but also prevent loss of the other
eye as in sympathetic ophthalmia. If the pro-
lapsed iris cannot be pulled back into original
position, either by atropin or eserin, then op-
erative procedure is advisable. A blow to the
eye by a blunt instrument may cause detach-
ment of the retina or ruptured chorioid and
edema of the retinal layer, without any ex-
ternal evidence of pathology. Infection in
these cases of perforation are not infrequent
and may cause panophthalmitis, i.e., infection
of the entire eyeball.
Acid and lime burns are not only painful
but may, and often do, cause ultimate blind-
ness because of resultant scars in the cornea.
These cases show an intense injection of the
eyeball and an involvement of the cornea.
Flushing with cold tap water several times,
as soon as possible, is a great help, not only
for relief of pain, but also to lessen the cor-
neal involvement. Installation of any oil,
holocain for relief of pain, tropin (if no
danger of glaucoma) and ice compresses the
first 24 hours will make the patient quite com-
fortable and will lesson edema of the tissues.
Adhesions between cornea and lids frequently
occur and should be prevented, if possible, by
70(i
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1D31
daily probing of the upper and lower lids. In-
volvement of the uveal tract, iritis— -irido-
cyclitis, or uveitis — usually follows marked
burns. Foreign body in the cornea, conjunc-
tiva or sclera is not serious or dangerous in
itself as a general rule. The danger lies in
the dreaded aftermath of infection. In the
cornea this infection, corneal ulcer or abscess,
is very important because even small scars if
situated in the pupillary space may cause loss
of vision and necessitate an operation (opti-
cal iridectomy) for the restoration of vision.
Traumatism to the eye may cause a flaring
up of a perfectly quiet constitutional disease
such as syphilis or tuberculosis of the eye.
Traumatism may also start an acute attack of
glaucoma.
The handling of an injured eye should be
conservative from the first, to maintain vision,
preserve appearance, and relieve pain. A most
trivial accident may, through ignorance or
neglect of the patient, result in total loss of
vision in the affected eye or both eyes. The
industrial worker should be taught that the
best first aid in most cases is to leave the eye
alone, to irrigate with cold clear water, use a
clean cloth and to go at once to his physician.
MEDICAL POSSIBILITIES OF SEA
WATER
C. L. De Meritt, M.D.,
Union City. N. J.
The idea of the sea as a source of health
is ancient. Greeks and Romans, profoundly
influenced in all phases of their lives by
the surrounding Mediterranean, developed
seaside resorts as modern nations have done.
To Venus, their ideal of female physical per-
fection, their religion ascribed a marine ori-
gin ; she arose from the sea. In our own
time, Lafcadio Hearn wrote: “Thou primor-
dial Sea, the awfulness of whose antiquity
hath stricken all mythology dumb * * * *
whence thine eternal youth? * * * * Still is thy
quickening breath an elixir unto them that
flee to thee for life.”
Romance may lie the precursor of scientific
realization, as witness Tennyson's poetic fore-
cast of aerial commerce and warfare. Our
present conception of salt water as a health
restoring agency is atavistic. Primitive peo-
ple of coastal regions probably recognized the
benefit of sea bathing before they evolved a
language to describe it. Now. there is enough
biologic, chemical and evolutionary data to
justify study of sea water thrown directlv into
the circulating blood of human beings, as food
for the tissues in conditions of poor nutrition.
The accepted, logical theory of the origin of
life being that it began in the ocean, millions
of years ago, as single-celled organisms deriv-
ing their existence directly from sea water, a
second theory may lie drawn from this first
one. For present purposes, we will restrict
this second theory to man though it applies to
vertebrates generally. It is that the human
cell, in all its specialized variations, has in-
herited from the primordial ancestral cell, a
physiologic craving for the chemical con-
stituents of sea water. This theory, though
it were mere assumption, would be justified as
a basis of investigation, but it also rests on
good circumstantial evidence. A primitive
multicellular type is an open sac whose wall is
a single layer of unspecialized cells. Sea water
flows in and out and at least 2 surfaces of
each cell are in contact with it. The body
wall, at a later stage, thickens, becoming a
mass of buried cells bounded by outer and
inner cell layers. The sea water reaches all
parts of the cell mass through channels pushed
out from the body cavity, and it begins to
carry prepared nutriment because the lining
cells of the cavity are acquiring the function
of digesting organisms of the preceding types
which, of course, continue to exist. As the
progressive types go on developing, this rudi-
mentary circulation must be replaced by a
pressure system, and channels are replaced
by a closed system of tubing, forerunners of
vertebrate blood and lymph vessels. A con-
tractile vesicle, forerunner of the vertebrate
heart, pumps the contained fluid through them.
So. each organism of advancing type carries,
within itself, its own little sea, which we will
call blood.
This blood, cut off from the parent sea, re-
ceives and delivers its water, its dissolved.
Sept., ltlol
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
707
salts, and its dissolved nutritive and excretory
material, by transudation through cell mem-
branes. But, as a fundamental solution of
inorganic salts, it is and must remain sea
water of the geologic period at which the
vertebrate type of circulation was developed.
The inorganic salts of the blood are now de-
rived from the food. Food being normally
in excess of requirements, the problem of
keeping the saline concentration of the blood
at the only figure the cells will tolerate, after
closure of the circulation, becomes one of
selective elimination. This problem is solved
bv the recently evolved kidney. From the pre-
Cambrian or early Cambrian period of ge-
ology, when vertebrate life was in the making
and blood and sea water had the same salt
concentration, down to the present, the sea,
according to scientific evidence, has been in-
creasing its concentration. But during all the
millions of years that have elapsed, the kidney
has. according to equally good evidence, kept
blood concentration at the original point.
This fascinating theory, now generally accept-
ed, was advanced by Macallum, in an article
published in the Transactions of the Phila-
delphia College of Physicians for 1917. Credit
is given here, because my obligations to this
scientist cannot be expressed adequately in a
footnote.
Sea water contains about 35 parts per 1000
of dissolved salts. These salts, in parts per
1000, are: Sodium chloride, 27.21; mag-
nesium chloride, 3.81 ; magnesium sulphate,
1.66; calcium sulphate, 1.26; potassium sul-
phate, 0.86; calcium carbonate, 0.12; mag-
nesium bromide, 0.08. Sea water also con-
tains minute amounts of iron, lead, copper,
maganese, barium, strontium, iodin, flourin,
and various other elements, free or in com-
bination. Even gold has been detected in it.
The mineral salt content of blood is much less
than that of sea water. Sodium chloride
forms the greater part of the salt content of
both fluids, but sea water contains about 5
times as much of it as does blood ; in a pre-
vious article, a mathematic error made me say
a little more than 3 times as much.
Macallum has estimated the percentage con-
centration of sodium, potassium, calcium and
magnesium in sea water and in various serums
and sodium is rated at 100 in each case.
The figures for sea water are : Sodium,
100; potassium, 3.6; calcium, 3.9; magnesium,
12.1. The figures for human serum are:
Sodium, 100; potassium, 6.1; calcium, 2.7;
magnesium. 0.9. The discrepancies between
these 2 sets of figures indicate that, since the
evolution of the kidney, the salts of the sea
have been concentrating at unequal rates, the
magnesium salts much faster than the others.
Geologic evidence points, more directly, to the
same conclusion. Sea water of the early
paleozoic era was, no doubt, a fine physiologic
fluid, with no doctors or patients to make use
of it. But sea water of the present era can-
not even lie made into a physiologic fluid by-
diluting it. “Quinton’s serum” is about iso-
tonic with human serum ; 190 parts distilled
water and 83 parts sea water, but it contains
0.89% sodium chloride, as against 0.56% for
human serum, and yet comes nowhere near
balancing the excess of magnesium salts.
While some chemical knowledge is essen-
tial, investigation of the therapeutics of sea
water should, in my opinion, rest mainly on
biologic and evolutionary grounds. I began
to study the subject on this basis 5 years ago.
I knew that others had preceded me, but I
did not know anything about their work, and
I decided that, conceding them all honor and
priority, I would learn more by working the
matter out independently.
I started with the idea that sea water might
be a tissue food, supplying certain tissues with
certain material, their supply of which had
been depleted. Given intravenously, it might
do this more rapidly and effectively than it
could be done through the digestive system.
Tissue repair is a slow process. It seemed as-
though small, frequently repeated doses would
be the best mode of administration. Another
idea, the origin of which I do not know, is
that sea water may, in some unknown way,
activate certain metabolic functions that are
failing. This is a purely theoretic conception,
but the subject of this article goes beyond the
present limits of biochemistry, and must be
worked out by first assuming theories and
then proving or disproving them by clinical
708
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
methods. Having decided on small doses, my
next object was to keep the amount of fluid
injected within the convenient limits of hand
syringes. This, of course, made it desirable
to use undiluted sea water, other things being
equal. Having a small urologic service in a
hospital, I there began giving intravenous in-
jections of undiluted sea water, rather indis-
criminately and somewhat to the mystification
of the rest of the staff.
The first doses given were 5 c.c. This was
gradually run up to 50 c.c. without any bad
effects being noticed. Later, I set the limit
at 30 c.c., because results indicated that
amount to be enough, and because a 30 c.c.
hand syringe is the largest size that I can con-
veniently use in routine work.
According to Martinet, the salt water for
“Quinton’s serum” is collected aseptically,
some distance off shore, at a depth of 10
meters and sterilized ( ?) by filtration. In
contrast to this, most of the water I have used
has been collected at Long Island beaches, at
the surface, within easy swimming distance of
the shore. The therapeutic value of sea water
may lie, in whole or in part, in materials
present in such small amount as to defy an-
alysis. If this is so, and the possibility is one
to be reckoned with, then such materials may,
quite conceivably, be most abundant in shal-
low water exposed to the joint influences of
sunlight and the ocean bed ; may even be, in
part, products of the beach itself, exposed
twice a day to the water and then to the air
and light. Our present knowledge of life
processes strongly suggests that life had its
humble beginnings in such an environment
rather than among raging waves. These
theoretic considerations accorded with the
practical one of getting clean water, free from
visible suspended matter. At first, most lots
collected did not meet this requirement. Later,
I found that on days when the surf was flat-
tened by off shore winds I could get water of
spring-like clarity over sand bars, in the vicin-
ity of inlets, at or near low tide. Thus, the
water I use is, in part, the outflow from Great
South Bay, a large, shallow, landlocked salt
water basin. Approved for bathing purposes,
as my supply is, I nevertheless had my own
tests made. Some samples showed colon
bacilli, but always far within the safety limit
for public water supplies.
On the day of collection, the water is run
through 2 layers of filter paper ; tap water
being run through first to remove possible
loose shreds of paper. After filtration, the
sea water is pasteurized by setting the con-
tainer in boiling water for 20 minutes. It is
pasteurized again the next day, and every 10
days thereafter, as long as it is kept in stor-
age. Furthermore, each dose is separately
refiltered and repasteurized the day it is given.
Mason jars are used for collection and chemi-
cal flasks for pasteurization and storage. Mv
present rule is to discard water stored longer
than 2 months. Injections are made at the
bend of the elbow, with a 30 c.c. all glass
syringe and a 5/8 inch, 23 guage needle.
Practical work to date covers about 700
injections given to about 100 patients; 37 had
12 injections given at the rate of 2 or 3 a
week. This is what I call, arbitrarily, a
course of treatment. One patient had a second
course, given 6 months after the first, and 5
others 1 jA to 2 courses with no intermission
after the first 12 injections. All patients were
adults.
So far, indications for this treatment have
been held down, strictly, to malnutrition and
nervous exhaustion in adults, although in the
beginning, before I had established any indi-
cations, I treated a few cancer cases in the
hospital. These indications are common enough
in an office practice like mine, composed
mostly of syphilitic and minor urologic con-
ditions. Patients suffering acutely from these
primary diseases were excluded ; also roues,
whose mode of living would negative the ef-
fect of reconstructive treatment. Lately, a few
cases of nervous exhaustion with no evident
causative or co-existent disease have been
treated. Most patients were not told that they
were getting sea water, lest the novelty of the
treatment should lead to exaggeration of re-
sults. Of the 43 who had 12 or more in-
jections, 3 had treatment for syphilis and 10
had intramuscular injections of iron cacody-
late during the same time.
Results, in such cases, are mainly to be
judged by what the patients themselves re-
port, and these reports have been very satis-
Sept., 1031
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
709
factory. A few illustrative cases will be more
interesting than a tiresome table of statistics :
( 1 ) A woman, aged about 40, always under-
weight and nervous, had a stone in the ureter 3
years ago ; passed under dilatation. A year ago,
she broke down under heavy family and busi-
ness responsibilities. Symptoms were loss of
appetite and weight, insomnia, mental and phy-
sical languor. General examination showed
only heightened reflexes. Twelve injections
of sea water in 4 weeks. Results, in her own
words: “Something has changed me. I eat
and sleep better, can apply my mind to busi-
ness, my muscles have some real action, and
people notice the change in me.”
(2) Man of 33. who had been treated a
year for old syphilis discovered through an eye
lesion. General examination and blood Was-
sennann negative. He had a laborious job
and was falling down on it — tired all the
time”. Twelve injections of sea water; bis-
muth treatment continued at the same time.
Result: His foreman remarked that he was
outdoing most of his fellow-workers.
(3) A thin, haggard janitress, aged about
35, near the end of a year’s treatment for old
syphilis. General examination and blood
Wassennann negative. Too tired to carry
on, nervous, slept poorly. Twelve injections
of sea water; bismuth treatment meanwhile.
Result : She gained several pounds, felt quite
up to her work, and was complimented on her
improved looks.
(4 and 5) Man and woman, both diabetics,
in the sixties, with localized gangrene which
did not improve much after the urine was
made Benedict-negative and blood-sugar
brought to near normal, until sea water
was used. The woman, whose case was re-
ported in 1929, had a relapse of sloughing
when sea water was stopped, followed by
complete healing after its resumption. On
several occasions, each of these 2 patients had
a chill after injection, and a rise of tempera-
ture which soon fell to normal.
(6) A well nourished man of 63, with
chronic leg ulcers. Syphilis, diabetes and gen-
eral arteriosclerosis excluded. Superficial veins
slightly varicosed. Three injections of sea
water. Chill and slight fever after injection,
followed by marked increase of the hyperemic
area around each ulcer.
Cases 1, 2 and 3 are representative of the
indications followed and results obtained in
most of the patients treated. Cases 4, 5 and
6 are the only ones, so far as I know, in which
reactions occurred, and they were the only
ones with active suppurative processes. Some
patients feel a transient sense of warmth
spreading over the body, during injection;
which is said to lie characteristic of magnesium
salts used intravenously. About 50 injections,
including some of those given cases 4 and 5,
have been followed up for glycosuria, which
has been produced experimentally in animals
by injection of dilute sea water and of mag-
nesium solutions. I have found no sugar as
yet and, if I ever do, will still have to be con-
vinced that its transient appearance means any
tissue damage.
My work indicates that the intravenous in-
jection of undiluted, pasteurized sea water, in
quantities up to at least 30 c.c., is a reasonably
safe procedure. It suggests that sea water,
used this way, has a definite, though probably
quite limited, application in therapeutics. It
has been an inspiring experience to me, to
have stumbled into a path of medical science
leading away from overworked laboratories,
drug factories and lamp factories, to the
Mother of Life, the Sea.
FOREIGN BODY IN THE URINARY
BLADDER
R. L. McKiernan, M.D., F.A.C.S.,
New Brunswick, N. J., and
H. H. Goldstein, M.D.,
Elizabeth, N. J.
Although foreign bodies in the urinary
bladder occur commonly enough, the follow-
ing case presents certain points which we be-
lieve are of sufficient interest to note. The
female bladder is perhaps more fiequently
insulted than the male, in this respect, because
of the short urethra in the female and the
ease with which a foreign object may slip into
710
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
•Sept., 1931
the bladder as compared with the longer and
narrower urethra in the male.
Case Report
F. K., Polish, unmarried, aged 22, was re-
ferred to the genito-urinary department of
the Alexian Brothers’ Hospital by Dr. M.
Holtzman, of Elizabeth, New Jersey.
Complaint-. Difficulty in starting the stream
and, at times, complete retention of urine. No
history of venereal disease. He states that
thus irritating himself, the patient offered the
following explanation. He had been ill, was
having difficulty in urination, and decided to
withdraw his urine by inserting the rubber
tube. Questioned as to why he had not used
a catheter, he revealed total ignorance of such
an instrument. At no time would the pa-
tient admit any knowledge of the toy rubber
balloon.
Physical Examination : The patient was
obviously of low mentality. He was codpera-
No. 1
Foreign Body in the Urinary bladder
about 6 months ago he introduced a short
length of rubber tubing into the urethra, and
it slipped away from him and he was unable
to extiact it. At first there were no symp-
toms but gradually he noticed some frequency
and burning, and then increasing difficulty in
starting the stream, with occasional acute re-
tention. < in July 30, 1930, he was again seen
by Dr. Holtzman, who referred him to the
hospital urologic service.
On being questioned as to his motive in
tive but offered scant explanation for his self-
abuse. Physical examination was essentially
negative, except that there was some supra-
pubic tenderness on moderate palpation.
Laboratory Findings: Urine very dirty and
loaded with pus and hlood. Blood sugar,
N.P.N.. creatinin, and urea-nitrogen, all with-
in normal limits. I he blood picture presented
nothing remarkable and the Wassermann test
was negative. Radiogram revealed a rubber
tube, as described by patient, lying coiled in
Sept.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
711
the bladder region; no x-ray evidence of the
toy balloon. (Fig. 1.)
Cystoscopy. July 22, 1930. The bladder held
approximately 100 c.c. Irrigating fluid was
loaded with floating debris. Mucosa red and
edematous, and the bladder wall thick and
trabeculated ; orifices obscure and the trigone
injected. Free in the bladder, rested a rubber
tube, folded and coiled on itself and covered
with calcareous deposits. Attempts at cvs-
toscopic removal were of no avail.
No. 2
Foreign Body in the Urinary Bladder
Operation. July 25, 1930. Under ethylene
anesthesia, a suprapubic midline incision was
made, the bladder exposed, and opened in the
conventional fashion. Lying free in the blad-
der could be seen a rubber balloon and with-
in it the short length of rubber tubing. I his
was removed, the bladder closed around a
Pezzer catheter, a drain was placed in the
space of Retzius. and the wound closed.
(Figs. 2 and 3.)
Convalescence was entirely uneventful. The
suprapubic catheter was removed on the
seventh day, and a penile catheter inserted;
removed 6 days later and 3 days after that the
patient was discharged.
Comment. Practices involving bodily, muti-
lation and calculated to give some measure of
sexual stimulation are quite frequently
brought to our attention. Often, but not al-
ways, there is evident mental deterioration.
The foregoing case demonstrated unmistak-
able evidences of deficient mentality. At first
No. 3.
Foreign Body in the Urinary Bladder
the patient tried masturbation with the short
length of rubber tubing, but this proved very
irritating to the mucous membrane of the
urethra, and balloon was then used as a re-
ceptacle for the rubber tube and the whole
inserted into the urethra. Masturbation could
then be encompassed without irritating the
mucous membrane. This went on until the ap-
paratus slipped completely into the urethra,
could not be retrieved, and brought the pa-
tient to the attention of his physician.
712
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
Collateral Reading
REAL AND UNREAL
Nearly everyone is at present interested in
psychology, psycho-analysis and kindred mat-
ters, and many of the recent novels, as well
as the biographies, have their reason for ex-
istence in this field of study. A good review,
by Arthur Ruhl, of a new book entitled “Real
and Unreal”, appeared in the Saturday Re-
view of Literature of June 13; which review
we herewith reproduce because it indicates
that you may find the book entertaining dur-
ing your vacation hours.
Boris Sokoloff is a Russian biologist who
also writes. His “Crime of Dr. Garine”, a col-
lection of short stories, appeared a few years
ago while he was associated with the Rocke-
feller Institute in New York. Before coming
to this country, he had been a member of the
Institute of Science in St. Petersburg and had
had experience as an experimental biologist.
To his experiments in fiction, therefore, he
brings a scientific point of view and a knowl-
edge esoteric to the average reader or writer.
This curious knowledge, and the cold, analy-
tic gaze which accompanies it, inevitably in-
trigues. I am not sure that they do not make
Mr. Sokoloff’s work seem more profound
than it really is — not certain, that is to say,
just how much the reader’s tendency to read
into his narrative significances beyond those
of the every-day novel is based on the actual
presence of such significance and how much
it may be explained by the author's peculiari-
ties of style and his somewhat obscure man-
ner of telling his story.
His purpose, as I understand it, in “Death of
Simon”, is to make a study, in fictional form,
of a certain type of divided personality, of a
man suffering from a disturbance of the en-
docrine glands. In Dr. Simon, the thyroid
and suprarenal glands are functioning ab-
normally. He is extremely sensitive, nervous,
emotional ; acutely impressionable, and seems
to see, in visions, what has been stamped on
his subconscious mind. In actual life, he in-
clines to avoid the crowd and the commoner
emotions, and to lose himself in an austere
world, peopled with flowers, the chiming of
church bells, and beautiful dreams. He is of
the type of the religious visionary. To re-
main in this more or less dream world, he in-
clines to suppress sex and the more earthly
instincts, a suppression which only heightens
the sensitiveness of the other side of his per-
sonality.
In the story he commits a murder — as the
law conventionally interprets the facts of the
victim's death — and part of the author's pur-
pose is to show that the supposed criminal in
such a case may be morally guiltless ; that he
should lie cured rather than punished. There
are. moreover, 2 women, who embody what
might be called Dr. Simon’s notion of “sacred”
and “profane” love. I find Mr. Sokoloff’s
handling of these women a little difficult to
follow but, as I understand the story, Dr.
Simon’s final discovery of a safe harbor in
Gertrude’s arms is intended to show the re-
turn of his tortured personality to a normal
balance ; to a humanity which recognizes and
accepts the so-called “baser” instincts, under-
stands, and forgives. Dr. Simon’s “death”, as
I understand it. is the death of that over-
wrought and unbalanced personality which he
had cultivated during the earlier years of his
life.
There is a suggestion of Dostoievsky in Mr.
Sokoloff’s work — not in manner or in nar-
rative skill — but in the type of human being-
considered. What Mr. Sokoloff does, in ef-
fect, is to take such a character as Dostoievsky
might have written about and endeavor to an-
alyze it, in fictional form, from the modern
biologist’s point of view. His story is not
altogether easy to read — the narrative jumps
about, this way and that, is full of curious
elisions. But it is, nevertheless, peculiarly in-
teresting, and becomes the more so on second
reading.
SEPTEMBER
These clays a boy will dart and dream
Like a speckled trout in an amber stream,
A girl walk lighter than yellow leaves,
And talk like rain in the brimming eaves;
But a woman will sit by an old gray wall,
Thinking of orchards ripe in the fall,
Or maybe of nothing, nothing at all.
There she’ll sit and never stir
'Till understanding touches her,
Or a warm wind wanders from the town,
And a great gold pear comes tumbling down.
Still she'll only sit and stare
At the precious fruit and the empty air,
Praising God for a single pear.
Honey-mellow and sunny-sweet.
Beautiful fruit is meant to eat.
Let her hold it a little while,
Touch it softly, and softly smile.
She will offer it with a sigh
To the boy or girl who happens by,
And sit in the sun, and wonder why!
— Rosalie Hiekler.
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
713
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J.
Entered at the post office at Orange, N. J., as second-class matter
PUBLICATION COMMITTEE
HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J
EDITOR:
HENRY O. REIK, M.D., F.A.C.S., Vermont Apartments, Atlantic City, N. J.
Each member of the State Society is entitled to receive a copy of the Journal every month Any member failing to
receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fa .
NOTE — The transaction of business will be expedited, and prompt attention secured if. t fared to
All papers news items, reports for publication and any matters of mescal or scientific interest, are sent direct to
The Editor, Dr. Henry O. Reik, Vermont Apartments, Atlantic City, • J- TmmN at books for review, advertisements,
All communications relating to reprints, subscriptions, extra copes J ' Chairman of the Publication
or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the
Committee, (address above), Newark, N. J.
WORKMAN’S COMPENSATION LAW
In his Presidential Address, Dr. Sommer
stated that in visiting county society meetings
he had heard much discussion of the Work-
man’s Compensation Law, and many com-
plaints about the manner in which it is en-
forced; complaints ranging over a wide field
and covering a variety of subjects from the
small fees paid by some insurance companies
to the “lifting of cases” by fellow practition-
ers. His recommendation, that a committee
be appointed to study the whole problem, was
approved by the House of Delegates. Pitsi
dent Plagerty has secured Dr. Sommer’s con-
sent to serve as Chairman of such a committee,
and has given him as committee associates,
Drs. Francis R. Haussling, Joseph H. Lon-
drigan, I. M. Vanderhoff, Elmer P. Weigel,
David A. Kraker, and James P. Morrill.
At the same time this committee is conduct-
ing its investigation, we have the advantage
of Dr. Morrison’s presence on the Advisory
Board that the Commissioner of Labor ap-
pointed last year, and whose preliminary le-
port was published in the May Journal.
It should also be remembered that Dr.
Morrison, in his Annual Report, as Secietaiy,
invited all members who have suggestions to
offer, for amendments to the law or for bet-
ter administration of the existing law, to
communicate with him before Octobei. So,
those who desire to present criticisms of, or
plans for improving, existing conditions may,
and should, now address themselves to Dr.
Morrison or Dr. Sommer, or to some member
of the above named committee.
NEWSPAPER PUBLICITY
Thousands of physicians, all over the world,
serve humanity by devotion to public health
work and die in office or pass along to the
“retired” list on account of age, or political
displacement, without any public notice being
given to their many years of labor or excel-
lence of service in the interest of human wel-
fare. The work of physicians so engaged is
peculiarly thankless. Their salaries are low,
even in comparison with the pay of other
public servants. They are seldom thanked
specifically, because what is everybody’s busi-
ness is nobody’s; and their names, even, pass
into oblivion with little more mention than is
to be found in the official record of appoint-
ment of their successors.
Recently, our attention was atti acted, pci-
haps because of its unusual chaiacter, to a let
ter in the London Times, of Saturday, August
8, signed by 6 of the most distinguished Eng-
lish physicians and surgeons, as follows:
A TRIBUTE TO DR. T. H. C. STEVENSON
To the Editor of the Times:
gjr — -We do not wish the retirement of Dr. T.
H C. Stevenson from his official work at the
General Register Office to pass without an expres-
sion of our deep regret on the event, and of our
appreciation of his public services.
714
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1031
Of Dr. Stevenson’s contributions to the scientific
journals we shall say nothing, except that these
would have sufficed to secure a permanent place
tor him in the history of statistical science. The
searching and illuminating discussions of the prob-
lems of vital statistics, which he has contributed to
the Census Reports and to the Annual and Decen-
nial Reports of the Registrar-General, have formed
noteworthy landmarks in the study of our national
records. Dr. Stevenson’s remarkable analysis of
the data of the census of fertility taken in 1911
was a tour de force, while the essays contributed
by him to the Annual Reports of the Registrar-
General make a wider appeal and. in our judg-
ment, place Stevenson second only to William
Farr among those public servants who have se-
cured for England her proud position in the realm
of official vital statistics. His studies of the fac-
tors of infant mortality, of the local distribution
and evolution in time of mortality from tuber-
culosis, and of the interpretation of the statistics
of cancer mortality, especially in relation to its
local incidence in the human body, are further ex-
amples of immensely important medical research.
Di . Stevenson first demonstrated, upon adequate
data, the contrasting rates of mortality of single
and married women from cancer of the breast and
reproductive organs; this, and his more recent
studies of the variation of cancer mortality with
social status, constitute probably the most import-
ant statistical contributions yet made to our
knowledge of malignant disease.
In these, as in many other instances, Dr. Steven-
son proved himself a worthy successor to Farr,
and there has been secured that continuity of re-
search into medicosocial problems of which the
Registrar-General's records form an almost un-
limited storehouse. We offer this imperfect trib-
ute to the merits of a great public servant in the
hope that our readers may reward him in the way
he would most value — by studying these records
of first-rate investigation for themselves and by
becoming stimulated to similar inquiries based on
our scantily used records.
We are respectfully,
Dawson of Penn
Moynihan
J. C. Stamp
. Arthur Newsholme
Major Greenwood
G. Udny Yule
We reproduce the above letter because it
appealed to us as an example of what physi-
cians can do in the line of public acknowl-
edgment and appreciation of the work of pro-
fessional associates, and of what they might,
in perfectly good taste, regularly do toward
informing the laity regarding the constant
and continuous public health protection being
given by physicians. To us, it appears to
constitute an example worthy of adoption a
method applicable to our public educational
piogram, and usable, too, as an offset to some
of the existing tendencies to criticize the
medical profession in unreasonable ways.
I' urthermore. this is a form of publicity not
subject to criticism on the score of ethics — it
is, rather, deserving of praise ; hence, we com-
mend it to the consideration of those — es-
pecially county medical society officers — who
‘ i d \ ocate wider use of newspapers, by organ-
ized medicine, for publicity. Opportunities
for such public recognition of the work of
our confreres are not infrequent, and we
might well use state and county papers for
complimenting those physicians who have
done or are doing good service, and for bet-
ter acquainting the people concerning what is
being done in their behalf.
REVISION OF PUBLIC HEALTH
LAWS
The preceding editorial brought to mind an
excellent example of a missed opportunity to
praise publicly the good deeds of one of out-
members, and to instruct the laity further re-
garding such matters.
About 3 years ago, Dr. Costill, after a per-
iod of most praiseworthy service to the state
as Director of Public Health, was inconti-
nently thrown out of office ; we not only made
no protest against using that office as a po-
litical football but neglected to express public-
ly our professional approval and appreciation
of his fine work.
Just recently, another change has been
made in the State Department of Health;
despite the fact that Director Bowen has
proved himself a very capable and efficient
officer, he has been disposed of as was his
predecessor. In so far as we are aware, no
public announcement has been made in eitlier
instance by way of explaining these changes.
V e have no complaint to make regarding the
recently appointed Director; for all we know
at this moment, he may be an ideal man for
the place. But. we dislike the procedure, or
method, employed in the making and break-
ing of such an important official as the Direc-
tor of Public Health in New Jersey.
During his incumbency of the office, Dr.
Costill frequently recommended changes in
the existing health laws, and Mr. Bowen, in
an address to the State Medical Society at the
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
715
Annual Meeting in 1930, also set forth the
desirability of a fairly complete revision and
asked whether the medical profession would
join in an effort to procure it. Unfortunate-
ly. there was no discussion of the symposium
of which Bowen’s address was a part, and no
authoritative answer was ever given to his
question. Hpwever, at the recent Annual
Meeting, provision was made for a special
Committee “to confer with the State Board
of Health, and other public health authorities,
on Revision of the State’s Health Laws”.
President Hagerty has named an excellent
Committee — chosen with great care — -under
the chairmanship of Dr. William G. Schauf-
fler. of Princeton; and the following addi-
tional members: Drs. Joseph C. Schapiro,
of Union City; Stanley H. Nichols, of Long
Branch; Frank C. Johnson, of New Bruns-
wick; and Julius Levy, of Newark. It is
hoped that this group will endeavor to bring
about several greatly needed improvements.
The first essential is, of course, to effect
such alterations as will best safeguard the
health of all residents of the state; i. e., public
welfare must be the committee’s prime con-
sideration. This society long ago constituted
itself guardian of the people in all health mat-
ters, and it fully intends to maintain that posi-
tion. In order to meet its obligations it must,
however, be given a larger part in the con-
trol of health affairs. So, for our committee,
that becomes the second important factor in
the developments of the proposed conference.
At present we have nothing like adequate
representation on the Board and, further, we
respectfully suggest that it should lie a legal
requirement that the Director, or Commis-
sioner, must be a physician. We recognize
the fact that on occasion the office has been
well conducted by a layman, and realize also
that some of the best City Health Officers m
this state are not doctors of medicine, but such
facts have been too greatly dependent upon
chance. In general, it would probably prove
wiser to require that a physician be chosen
for head of a state department whose work
is so preeminently medical.
Travel Article
A VISIT TO THE ROYAL VICTORIA
HOSPITAL. MONTREAL
(A letter from John Hammond Bradshaw, M.D.,
F.A.C.S., Orange, New Jersey.)
No medical man stopping at Montreal
should fail to visit the Royal Victoria Hos-
pital. I have said before that hospitals are
like people, different only outside but much
the same inside. For a more unique and
beautiful exterior with a more unusual set-
ting one will travel a long way and visit many
cities and many countries before such a hos-
pital as the Royal Victoria will he seen. Like
Rome. Montreal is a city of many hills; but
no other city in the world has Mount Royal
towering many hundreds of feet above the
city's noise and grime.
Now, picture to yourself a hospital on a
mountain, built of gray rock, consisting of
10 or more large buildings of Norman archi-
tecture surrounded by densely wooded slopes
of old forest trees and looking down quietly
(like a guardian angel) upon the city of Mon-
treal far below at its feet, a city of between
on-e and two million souls.
The Royal Victoria is not the only large
hospital m Montreal. I he Montreal General,
I believe, is larger, but it holds about the
same relation to the Victoria as the London
Hospital does to St. Thomas’ Hospital on the
Thames Embankment. The Montreal Gen-
eral is built low down in the heart of the
poorer quarter of the city and is not as mod-
ern as the Victoria. But within the walls of
the Montreal General work many of Canada s
most noted medical and surgical men. More-
over, if one motors a short distance from the
city, one will pass a pure French Canadian
Hospital whose very sign will make one gasp.
The doctors who are working in this institu-
tion. I am told, take nobody’s dust.
Montreal (named after Mount Royal by
Champlain), the greatest city of Canada,
whose site was discovered but 50 years after
Columbus discovered America, is also one of
the oldest, and is the Mecca for many pil-
grimages seeking medical and surgical relief,
not only for Eastern Canada but, I am told,
for thousands of people living in our own
United States, particularly those living in the
northern counties bordering on this His
Majesty’s principal great Dominion. , The
Montreal hospitals “deliver the goods and
the fees for medical and surgical work are
most reasonable. Even the nursing costs but
716
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
two-thirds of the cost of nursing in New
York City and its vicinity.
I his hospital is not, like St. Bartholomew’s
in London, an ancient one. It only dates back
to the end of the last century. It was organ-
ized and founded with great vision by the
Right Honorable Lord Mount Stephen and
ihe Right Honorable Lord Strathcona and
Mount Royal. On its present Board of Gov-
ernors we find such names as the Mayor of
Montreal, the President of the Board of
Trade, the President of the Bank of Mon-
treal. E. W. Beatty, K. C., the President of
the Canadian Pacific Railway Company, the
President of the Canadian National Railways,
the President and Dean of McGill University,
as well as other well known names. One can
readily understand the wisdom and the fore-
sight of getting such people interested in a
hospital. This idea, I believe, is a good one
for many of our own institutions to adopt.
Just run your eve again over these names, and
try to imagine the full scope of their influ-
ence ! You may say these men’s names are
only “window dressing”, but I am told that
this is not so and that Beatty, who controls
what is probably the greatest system of rail-
ways, hotels and steamships in the whole
world (the Canadian Pacific), gives to the
Royal Victoria Hospital freely much of his
time and great administrative talents.
As one enters the principal entrance, one
first sees a very beautiful life-size marble
statue of good Queen Victoria holding in her
sheltering arms 2 little children. There are
so many buildings to see, one is at a loss which
way to turn. As the hospital is built on a
cliff of a mountain, almost all of these hos-
pital buildings are connected with one another
by long, well-lighted tunnels. I first went to
the operating rooms (there are 10 of them in
the institution). These are built in the ap-
proved fashion of the year 1900, with walls
lined with 3x5 slabs of white marble. As the
hospital is part of McGill University Medical
School, there are amphitheatres of large seat-
ing capacity in 'a number of these rooms. Here
work E. W. Archibald, B.A., M.D., F.A.C.S.,
F.R.C.S.; C. B. Keenan. D.S.O.. M.D.. F.
A.C.S.; F. C. McKentv, M.D.. F.R.C.S., F.
A. C.S.; Francis A. C. Scrimger, V.C., B.A.,
M.D., F.A.C.S. ; Wilder G. Penfield, Litt.
B. (Princeton), M.D. (Johns Hopkins), M.
A., B. Sc. (Oxon), one of America’s greatest
brain surgeons; D. W. MacKenzie, B.A.,
M.D., F.A.C.S., who is so well known in the
urologic world; J. R. Frazer. M.D., F.A.C.S.,
one of Canada’s great gynecologists ; and
many others who are leaving their surgical
footprints on the North American Continent.
As there are about 50 doctors on the House
Staff alone, one sees the impossibility of giv-
ing all the names.
I witnessed a number of urologic opera-
tions and an operation for a comminuted frac-
ture of the leg. This was skilfully and very
quickly performed by cutting down to the dif-
ferent fragments and suturing them with
heavy chromic catgut to the tibia. Approx-
imation was perfect and the wound closed
and leg put in plaster cast. Dr. Scrimger is
one of the most active surgeons here, and is
most highly regarded. He was just complet-
ing a most critical and difficult job on a poor
fellow, the victim of an aeroplane smash (it
was a decided human smash as well!). The
skull and other bones required work. I had
a long talk with this surgeon, who explained
in detail why in such a case he still uses Lane
plates. His arguments, back up by the detail
of the results in other cases, were sound. I
am aware that certain New York surgeons
would froth at the mouth, but personally I
myself believe that Lane plates still have their
uses. Dr. Scrimger, let me say in passing,
won his Victoria Cross in the World War.
Picric acid seemed to be the favorite skin an-
tiseptic in the work I witnessed. I never saw
more than 2 nurses work in each operating
room, but they are well trained.
Before closing this long letter, I should like
to give a few facts and figures regarding the
Royal Victoria Hospital. During the past
year the patients aggregated 14.597. The
operating deficit for the year was $19,661.66,
“which under the present conditions max be
regarded as satisfactory”. (I myself have
italicized this last clause.) The average cost
a day per patient in private rooms is $6+ and
in wards $4-)-. Year by year there is an en-
deavor to shorten each patient’s stay in the
hospital, and in this they are succeeding, thus
reducing cost.
The maternity department is very fine. To-
tal confinements last year, 2412; deaths 16;
mortality about .6; forceps used 390 times;
cesarean sections 53 — 1 death.
The Social Service, Prenatal, a “Depart-
ment of Nutrition”, the Radium and X-Ray
Services are well equipped and most active
and efficient. The gynecologic department is
almost as active as the general surgical. The
medical department is under J. C. Meakins,
M.D., LL.D. (Edinburgh). F.A.C.P., F.R.C.
P. (C.), F.R.C. P. (Edinburgh), F.S.S.C., F.
R.S.E., and should be visited to be appreciated.
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
717
Medical Ethics
“C’EST FORMINABLE L’OPINION
PUBLIQUE.”
John Hammond Bradshaw. M.D., F.A.C.S.,
Orange, New Jersey
One may believe it or not, but this caption
is accurate. If anyone has the slightest doubt
as to its truth, let him perform some outre act
and get found out! He may not be immedi-
ately aware of any change in public opinion
and, like many of the wicked, he will seem to
flourish like the green bay tree for a long
time, but at last disaster, like an avenging
Nemesis, will one day overtake him. This
seems to be one of the laws that puny man,
with all his pride, his assurance or his wealth,
cannot escape.
One often proudly thinks he can mold pub-
lic opinion. One also knows that public opin-
ion changes ; it is different in different cen-
turies and in different lands. It is also dif-
ferent in different strata of society.
To a doctor, this subject has an especial
significance. In many communities no fiercer
light beats upon any throne than upon a doc-
tor’s comings and goings, his pronouncements,
and even upon his manner of life. Of course
this is quite flattering to his self-esteem. It
also has its disadvantages. He often finds
that he is handicapped in his wishes. Mr.
Rich seems to be able to do almost anything
(even to skating on thin ice) and get away
with it. Does he not still pass the plate in his
fashionable church? Why do his financial
operations always have a golden glow? It is
often discouraging to the plodders and to the
poor who try to walk a straight and chalky
line.
But, if virtue is its own reward, it is not its
only recompense. To those of us who have
lived a few years there is a world of satisfac-
tion in the belief that right will prevail in the
long run, for we have seen it.
We cannot afford to offend public opinion.
It costs too much to do it! We can think of
many a righteous man who deluded himself
that it could be done. We admire Judge Ben
Lindsey for much of his work that is great
and good, but would we like to change places
with him today? He is not singular. There
are also many, many others. Perhaps in a few
decades we will say Judge Lindsey was right
and we were wrong.
But it is the public opinion of today to
which this caption refers, and we still are liv-
ing today, and today is in the year of our
Lord 1931.
Esthetics
THE WINDMILL ORCHESTRA
CONDUCTOR
Having received practically no musical
education, and being never the less very fond
of music, especially that of a good orchestra,
we have often wondered to- what extent the
labors — or gymnastics — of an orchestra leader
were really necessary. The Literary Digest
of June 27 provided the answer in an article
abstracted from The American Weekly ( date
not given) of New York. For the benefit of
colleagues of equal ignorance concerning
music we reproduce a portion of that article.
Orchestral conductors are of various kinds.
Some are so acrobatic that trouble on oc-
casion overtakes them. Such a one was a
famous English conductor in New York, who
broke his suspenders, and only averted dis-
aster by strategy. Richard Strauss, the famous
Austrian composer and leader, is one of the
quiet ones, and he has been quoted as saying
that “the antics of the spectacular, modern
orchestra leader are not only stage play and
unnecessary, but a poor compliment to the
members of his orchestra’’.
“Nobody doubts that every attitude and
motion is vitally necessary, and that without
this superman on the raised pedestal — well,
nobody knows what an awful mess and mix-
up that 30 or 40 or 50 or 95 men would get
into. One would think they were a lot of
musical Bolsheviks held in order only by this
I musical dictator, who sinks down perspiring
and exhausted at the end of his victorious
struggle. The joke is that when these same
men are rehearsed in the privacy of the band-
room, their leader does none of these gym-
nastics until they are all set ; and only then,
when it won’t upset his musicians, does he
rehearse his own part of the show.
Not knowing this, the audience is con-
vinced that if this genius with a baton didn’t
toss his fevered brow in the air and flash that
appealing look, the kettle-drums would not
come in when they should; and if it were not
for that splendid lion-like shake of the long-
haired head and the commanding gesture, like
a traffic policeman preventing a charging
718
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept.. 1931
truck from crushing a fallen child, they would
keep right on and ruin the piece.”
“In a recent editorial comment on the
Strauss statement it was asked : ‘Don’t they
really know when to play loudly or softlv or
when to come in f As a matter of fact, they
know perfectly well, and it is all written down
for them on the music sheets in front of their
faces. Any one who didn’t know that much
would hardly belong to a first-class orchestra.
Probably only a band of amateurs would be
helped by these cheer-leader, jumping-jack
tactics.”
“A trumpeter sitting far over on the right
of the stage, with 3 trombones and a lot of
drums behind him. has difficult}' in hearing
the first violins, some 30 feet away. At any
time he may need a cue from some one in
the center of things, but the lifting of a
finger is enough. The music does not have
to be jerked out of him by force. Nor does
he require what looks like a threat of violence
in order to stop at the right time. A hint would
lie sufficient.
L ntil the end of the last century the or-
chestra conductor usually did little more than
give time signals, and was not a highly paid
or featured performer. Also there was little
pretense on his part of interpretation. In
those days the feature was some eminent solo-
ist who gave the interviews, received the ad-
vertising, and brought the crowds. How in-
signifiant leaders were at that time, and how
it astonished the players when the public be-
gan to give the time-beaters credit for results,
is shown by the remarks of Pablo Sabasate,
some 30 years ago. This violinist is recorded
as having said :
‘What do you think ! They don’t play at
all. They just go around with a little stick
and wave it over the orchestra, and they get
paid for it. I he public seems to be getting
the impression that these fellows actually
make us musicians play'.”
1 hat a conductor can do almost anything,
no matter how startling and unexpected, and
rely upon his musicians to carry on, is reveal-
ed by the curious accidents that befell Sir
Thomas Beecham. the celebrated English con-
ductor who was alluded to at the beginning :
“At Philadelphia, in his antics on the plat-
form. he managed to sprain an ankle, which
cramped his activities, because he had to stand
still and carry his weight on one foot, and in
later performances he kept the injured one
on a pillow, but the concerts were a great
success. In New York, conducting the Phil-
harmonic, he suffered another casualty. So
furious were his exertions in wrenching the
music from the musicians that his suspenders
broke under the strain, and he almost lost his
trousers. This was even worse than a sprain-
ed ankle, because it kept both legs together,
and most of the time one hand in a trousers’
pocket. In emergencies, when he felt it neces-
sary to wave both hands, this gesture was
instantly followed by a frantic clutch at his
waist. In spite of these cruel handicaps, the
audience cheered. It was his greatest Ameri-
can triumph.”
Two conductors, familiar to American aud-
iences, Toscanini and Stokowski, are cited
among the temperaments :
“The great Toscanini hit an offending
violinist over the head with his baton. The
violinist saw the blow coming and tried to
ward it off with his bow. But the bow broke
and the blow landed. Worse than that, a
splinter injured the fiddler’s eye, and he
brought suit for damages. A psychologist
testified that to such a temperamental artist
as Toscanini hearing a violinist play flat was
enough to unseat his reason for the moment.
He would be filled with a blind impulse to
silence the offender in the quickest possible
manner, and therefore must not be held ac-
countable. Had it been the case of a boss
and a workingman, this theory might not
have impressed the court. But it happened in
Italy before a judge and a jury of musicians.
It would be difficult to get native Italians who
are not musical experts, and their faces hard-
ened when they heard that the injured man
had played flat.
Leopold Stokowski, conductor of the Phila-
delphia Orchestra, is the outstanding show-
man among conductors in this country. He
is widely known for his unorthodox methods,
particularly his precipitate entrance from the
wings to the conductor’s platform, and the
suddenness with which he launches the music.
Before he gets both feet on the stand his
baton has swung down, the lights in the audi-
torium are dimmed, and the concert is in full
swing.
Stokowski undoubtedly is a talented con-
ductor. but many of his original methods of
staging a concert are done to impress the aud-
ience. They do not increase the respect and
cooperation of the musicians working under
his baton.”
Sept., 1931
719
JOURNAL OF THE MEDICAL
In Lighter Vein
Turn It Inside Out
Mr. Kangaroo — “But, Mary, where’s the child?”
Mrs. Kangaroo — “Good heavens! I’ve had my
pocket picked." — Christian Advocate.
Pampering Junior
“What did you give baby for his first birthday?”
“We opened his money-box and bought the little
darling a lovely electric iron.” — Sydney Bulletin.
See the Folks First
Tommy — “Mother, let me go to the zoo to see
the monkeys?”
Mother — “Why, Tommy, what an idea! Imagine
wanting to go to see the monkeys when your
Aunt Betsy is here.”- — Lever.
Time Service
Mary had a little lamb,
Her father shot it dead,
And now it goes to school with her
Between two chunks of bread.
— Boston Transcript.
Playing Safe
Feminine Voice (telephoning) : “Is my husband
at the club?”
Porter: “No ma’am.”
Feminine Voice: “But I haven't told you who I
am,’ ’
Porter: “Ah knows dat, lady, but they ain’t no-
body’s husband heah nevah.”
A new magazine is published by and for luna-
tics. It is unique only in admitting the fact. — Flor-
ence (Ala.) Herald.
“Ink can be put to many good uses”, states a
scientist. Some one should tell those spring poets.
— Passing Show (London).
Some take a spring tonic for that run-down
feeling, but pedestrians need a stretcher. — Flor-
ence Herald.
The sap is an indication of vigor in all trees
except family trees. — Louisville Times.
Not Half Stripped
During the hearing of a case, the Judge was dis-
turbed by a youth who kept moving about in the
rear of the court.
“Young man”, he explained, “you are making
a good deal of unnecessary noise. What are you
doing?”
“I have lost my overcoat and am trying to find
it”, replied the offender.
“Well”, said the Judge, “people often lose whole
suits in here without all that fuss.” — Philadelphia
Public Ledger.
SOCIETY OF NEW JERSEY
Lighthouse Observations
PRACTICAL USE OF SPINAL ANESTHESIA
When the Fifth Judicial District Meeting was
held in Atlantic City, April 10, 1931, there was ex-
hibited an excellent moving picture which demon-
strated the technic of spinal anesthesia and illus-
trated some of the uses of that form of anesthesia.
There is no question but that spinal anesthesia is
now being more widely employed than was dream-
ed of even 2 or 3 years ago, and at the same time
we mention the increasing number of surgeons
employing spinal anesthesia, and its expanding
field of application, we can note its progressive
conquest of individual operators. For instance, V.
Earl Johnson, one of our own state society mem-
bers, in the American Journal of Surgery (March
1931, p. 478), relates his personal experience and
tells how he and his hospital associates were grad-
ually convinced of the usefulness and advantages
of spinal anesthesia.
“When I began the use of spinal anesthesia in.
January 1928, it was because its use was a neces-
sity, the case being a fractured femur in a person
with advanced prostatic obstruction, requiring an
open operation. I ran up against a rather firm
opposition to its use in our hospital. It was made
a subject of discussion and the question came up
as to whether I would be allowed to use it there.
At the present time, however, the attitude is
changed to the extent that I have been requested
to give spinal anesthesia for every surgical chief
on the hospital staff, and on the genito -urinary
service it is the routine method. From an almost
absolute condemnation of the procedure, it has
come to be very openly accepted.
During the time I have been using spinal anes-
thesia I have come to some very definite con-
clusions, to wit:
(1) Spinal anesthesia is a method that has come
to stay. It is safe when used in properly selected
cases.
(2) It should not be given by anyone but an ex-
pert. I do not subscribe to the opinion held by
some that spinal anesthesia may be administered
by anyone who can do a lumbar puncture.
(3) Spinal anesthesia is an ideal anesthesia for
the following conditions: (a) intestinal obstruc-
tions of all forms; (bj obstructions of the
lower urinary tract: prostatic hypertrophy,
stricture of the posterior urethra, subcervi-
cal nodes, etc.; (c) urinary extravasations with
toxemia; (d) major amputations of the lower
extremities; (e) for surgery of diabetics; (f) for
surgery below the diaphragm in patients suffering
from pulmonary tuberculosis; (g) for surgery in
certain heart and kidney diseases; (h) for those
cases of acute abdominal conditions where there
is a question of pneumonia.
(4) Spinal anesthesia, while not absolutely in-
dicated, has special usefulness in the following-
conditions : (a) treatment of fractures of the lower
extremities; (b) rectal work of all types; (c) . per-
ineal and vaginal operations; (d) intraabdominal
surgery of the female reproductive organs; (e)
any operative procedure below the diaphragm, re-
quiring as much as 1V2 hours to complete — shock
is eliminated; (f) ruptured duodenal or gastric ul-
cers.
(5) I do not believe that the ordinary run of
operations of the upper abdomen on good risk
patients can be done with a greater degree of
safety under spinal anesthesia than with ether or
72#
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
gas-local combination. If the patient is a poor
risk, because of associated damage to heart (q. v.),
lungs, or kidneys, or if the patient is diabetic, the
safer method is spinal anesthesia.
(6) Postoperative complications are markedly
reduced. In this series there were no respiratory
complications. One patient developed gastric di-
lation, from which recovery was rapid.
(7) The mortality rate for bad risk cases is
markedly reduced. All deaths occurred as a re-
sult of the primary surgical condition. On the
genito-urinary service the death rate is now only
3%, and the majority of the cases operated upon
are prostatic cases. The deaths on this service
are mostly advanced urinary extravasation cases.
Only one prostatic patient died and that was due
to suppurative peritonitis.
There are actually very few contraindications to
the use of spinal anesthesia. They are tabulated
as follows:
(1) Infections, including ordinary pustule
(pimple), at the site of the puncture.
(2) Very low blood pressure. One must be very
cautious in its use if the systolic pressure is be-
low 100.
(3) Septicemia cases.
(4) Consensus of opinion is that operations
above the diaphragm are more safely performed
under other forms of anesthesia.
(5) Cardiovascular: decompensated cardiac
muscle, Stokes-Adams’ disease, inordinately high
pulse pressure (relative).
(6) Cerebrospinal: (a) tuberculosis; (b) syphilis;
(c) brain tum|or; (d) cord tumor; (e) meningitis
— any type; (f) turbid spinal fluid.
MENTAL HYGIENE AND INDUSTRY
In last month’s Journal we dealt in this column
with Mental Hygiene and the Child. It seems now
appropriate to reproduce the following editorial
from the Pennsylvania Medical Journal of June:
“Industrial management or personnel adminis-
tration is that phase of industrial or mercantile
management which concerns itself mainly with
the human factor. The problems which present
themselves are innumerable and affect many
phases of human activity. The mere effort of get-
ting a living is a fertile source of maladjustment.
The major portion of our population belongs to
the industrial class. Therefore, anything that can
be done to assist the worker to adjust himself ef-
fectively to himself, the job, his home, and to his
social environment, is more than a contribution
to the employer and to the individual. It is a
contribution to the health and happiness of the
community as a whole.
Industrial medicine and hygiene have demon-
strated their right to a mace in the field of in-
dustry. The mental health of employees increas-
ingly demands attention of the industrial physi-
cian, business executives, and personnel staff. The
agitator, the chronic grouch, the eccentric, the
job misfit, and the man who fails are not merely
candidates for job transfer or the blue slip. The
choice of executives, job placements, guidance of
young workers, selection of machine operators and
automobile drivers are no longer matters of hunch
and intuition. These are matters for careful study.
It is in dealing with these broad problems of per-
sonnel selection, the maladjusted, grievances, the
physical and mental causes of accidents, that psy-
chiatry makes its contribution to the industrial
field.
Although mental hygiene as applied to industry
is in many respects still in the experimental stage,
certain definite trends have been established in
which the psychiatrist, the psychologist, the psy-
chiatric social worker, all play their parts. Psy-
chologic tests in the hands of trained psychologists
constitute a means of measuring certain achieve-
ments, performances, capacities, and behavior pat-
terns under standard conditions. The psychiatric
social worker enters the industrial field to study
those problems which concern the life of the
worker outside of his industrial contacts, and to
cooperate with the management in carrying out
the suggestions made by the psychiatrist or those
involved in the personnel management. The psy-
chiatrist has by training and experience acquired
a deep understanding of the mental processes of
both the mentally sick and the supposedly normal
individual. He readily detects the psychotic, the
mentally defective, and the frankly psychoneurotic.
But he is equally keen to recognize and give ser-
ious consideration to those prejudices, fears, wor-
ries, anxiety states, depressions, pessimistic moods,
hatreds, jealousies, grievances, and unhealthy
mental preoccupations and attitudes to which may
be attributed a large proportion of work failures,
maladjustment, and social discontent. He sees
the unhealthy mental condition. But he also takes
into account and weighs the whole situation,
the man's inherent abilities, his environment at
the plant and at home, the economic and the social
factors. Dealing with the workers, their indi-
vidual and group problems, the psychiatrist is in
a position to know the minds of the executives
and the workers, to see their problems and their
grievances, and to foster mutual understanding, hap-
piness, cooperation, and a spirit of loyalty among
workers, management, and employer. This work-
ing team of psychiatrist, psychologist, and psy-
chiatrically trained social worker brings to those
problems the psychiatric or clinical point of view
— that point of view which emphasizes all the fac-
tors in a given case, the physical, the mental, and
the social, thereby contributing to the solution of
these problems all the resources that modern medi-
cine, psychology and social work have to offer.’’
Public Relations
MALE (PROSTITUTE CONVICTED
(From Public Health News, Trenton, issue of
June-July, 1931.)
The first man to be convicted as a prostitute
and sentenced to a penal institution in New Jersey
was recently removed to the Rahway Reforma-
tory from Paterson.
It is not unusual for women to be arrested on
charges of prostitution and sentenced to state in-
stitutions. However, the success of Mrs. N. A.
Wickes, the protective officer of the Paterson
health department, in having a similar procedure
followed in the case of a male prostitute, deserves
special mention.
The man in question first came to the attention
of the health department in 1920 when infected
with gonorrhea. He promised to take treatment
from his own doctor but failed to do so and evaded
discovery for some time. Later he married a girl
who became a prostitute and was twice sentenced
to Clinton Farms.
During the 10 years after the man’s first con-
tact with the Paterson clinic, several women who
came to the attention of the protective officer
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
721
named him the father of their illegitimate children
and charges of bastardy were preferred against
him. By moving about from place to place, and
through legal technicalities, he was able to escape
punishment, however.
In November, 1930, this man was named the
source of infection of a syphilitic infection in a re-
port received by the State Department of Health.
When notified of this fact, the health officer of
Paterson had an investigation made and appealed
to the county prosecutor, calling attention to the
man’s long career of promiscuity. As a result, the
offender was arrested under authority of Chapter
240 of the Laws of 1922, charged with being a pros-
titute, was convicted and sentenced.
CONSULTATION SERVICE AT MOUNT SINAI
HOSPITAL FOR PEOPLE OF MODERATE
MEANS
(From the New York Medical Week, July 11, 1931)
Aims
A “Consultation Service”, restricted to patients
of moderate means referred by their family physi-
cians, is to be established by members of the Medi-
cal Staff of the Mount Sinai Hospital in coopera-
tion with the Administration of the Hospital. The
“Service” is designed as an aid to physicians of
the community in the investigation of patients
with clinically obscure conditions requiring multi-
ple consultations and laboratory examinations in
order to establish a diagnosis.
The Service is based upon the conviction that
public interest requires preservation of the family
physician, and that the full advantage of com-
petent medical care can best be achieved under his
continuous guidance — but that in order to accom-
plish this he must be provided with complete and
easily available diagnostic facilities to supplement
his own resources.
Eligibility
As the aim of this Service is to cooperate with
practitioners in the medical care of people of
limited means, the economic level of eligibility is to
be a maximum income of $2400 a year for unmar-
ried individuals and $400 for total family income.
For families of more than 5 members an extra al-
lowance of $400 will be added for each additional
dependent. Physicians are requested to refer only
patients who fall within thid economic group.
Patients will be expected to give satisfactory in-
formation concerning salaries or other income,
rent, and the names of employer and landlord.
Staff
The staff of the Consultation Service will be
comprised of internists, surgeons and specialists
who are members of the Visiting Staff of the Hos-
pital.
Site
The Service will function as an independent,
detached unit of Mount Sinai Hospital and will
occupy space in the hospital’s new building at 1
East 100th Street, New York City.
Fee
Tentatively, a flat fee of $35 will be charged all
patients regardless of the nature of illness or
number of consultations or laboratory examina-
tions that may be required. To avoid interference
with the practice of individual consultants, the fee
for a comprehensive examination is purposely set
at about double the average charge to a patient
of this class for an individual consultation or ma-
jor laboratory examination. An effort will be made
to maintain a flat fee schedule in preference to a
sliding scale. The Mount Sinai Hospital obligates
itself not to derive any profit directly or indirectly,
from its participation in this project.
Family Physician
Patients will be seen only by appointment made
through their physicians, who are urged to ac-
company them whenever possible. Members of the
Service Staff will maintain the ethical relation-
ship of consultants.
Consultation Hours
The consultation hours will be Tuesday, Thurs-
day and Saturday from 1.30 to 4 p. m,. A secre-
tary will be in attendance at all times, however,
with whom appointments may be made in advance
by telephoning.
Criticisms Previously Raised
Diagnostic clinics heretofore established have
met with one or more of the following criticisms:
(1) The clinics accept patients who are not re-
ferred by physicians, carry out all forms of
therapy and thus practice medicine in competition
with the family practitioner.
(2) Clinics are manned by physicians who do
not possess adequate scientific training and clini-
cal experience.
(3) Some diagnostic clinics are merely part of
a general public dispensary and the primary prin-
ciple, to keep the patient in the hands of his physi-
cian, is in conflict with the function of the public
dispensary which takes over the complete man-
agement of the poor patient.
The Mount Sinai Plan
The Mount Sinai Consultation Service is being
organized, staffed and administered by internists,
surgeons and specialists who are members of the
visiting staff of the hospital.
No patients will be accepted unless referred by
their physicians.
The work will be limited exclusively to diag-
nosis.
Upon completion of the clinical investigation, the
patient will be promptly returned to the referring
physician, who will receive, as complete a diag-
nostic opinion as possible, together with detailed
advice concerning appropriate therapy. No therapy
will be practiced, but the physician who refers a
patient will be at liberty to avail himself of the
advice and guidance of the staff in carrying out the
therapeutic procedures recommended.
Future
The participating physicians, comprising 90% of
the visiting staff of the hospital, regard the in-
itiation of this type of public service as an ex-
perimental step in placing the professional and
physical facilities of a large, well-equipped, gen-
eral hospital at the disposal of practicing physi-
cians of the community for the benefit of patients
of moderate means. The Consultation Service will
only be continued and expanded if it proves to
have justified its existence by the end of the first
year, and to have been adequately utilized by the
722
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., LGl
physicians of the community for patients belong-
ing to the class it is designed to serve.
The Consultation Service will be ready to receive
patients in the autumn of 1931. The exact date will
be announced later.
GENEROSITY KI NS RIOT
(From the Indiana Journal, June 1391.)
Recently, we have been reading some circulars
and pamphlets sent out by the American Legion
concerning the prodigality of the United States
Government in furnishing a lot of compensation
and gratuitous services that are costing the gov-
ernment a fabulous sum of money every day and
the expense of which will increase as time goes on.
The soldiers’ bonus may have been a godsend to
a comparatively limited number of ex-soldiers but,
if all reports are true, most of those who obtained
the bonus spent it very promptly and extrava-
gantly for luxuries. Fon instance, the public press
published one item to the effect that out of 700
ex-soldiers in one community who received a
bonus, over 500 of the number used the money
as first payment upon more or less expensive
automobiles. What interests medical men is the
uncalled-for generosity in providing sick benefits,
including hospital care, for not only the ex-sol-
diers but members of their families. The United
States Veterans’ Bureau already has dispersed
more than $5,000,000,000 for the care of the dis-
abled and their dependents, and in 1930 Congress
made available for this purpose more than $500,-
000,000 to be expended by the Veterans’ Bureau
during the current fiscal year. Furthermore, the
sum of $121,950,000 has been authorized by Con-
gress for the acquisition, construction and altera-
tion of the United States Veterans’ Hospitals. As
a result of this authorization the Veterans’ Bureau,
it is said, will have more than 63 modern, fireproof
hospitals with a bed capacity exceeding 26,500, and
Congress is being urged to provide additional beds.
The American Legion is sending out circulars
from which we quote the following: “Do you
know that if you are in need of hospitalization the
United States Veterans’ Bureau will grant you free
hospitalization, which includes rooms, board, doc-
tors' care, surgical care, nurses’ care, medicine,
physical examination, x-ray pictures, electrical
treatment — in fact, free treatment of every known
disease? Do you know that you also are entitled
to free railroad or auto transportation to a govern-
ment hospital and free return trip home? Do you
know that in case an ambulance is needed to
transport you to the hospital or to a railroad sta-
tion in making a trip to a government hospital,
this also is furnished, as well as an attendant to
accompany you if your condition is such as to
warrant it?’’ Other perquisites pertaining to death
and funeral expenses are mentioned, and then the
statement is made: “All of the above is offered
to you free, regardless of whether or not your
disability is incident to your World War service.”
(italics ours)
We believe that the World War veterans de-
serve generous consideration, and especially those
who have disabilities that can be traced to their
service, but we believe, as is believed by thousands
of the veterans themselves, that liberality and gen-
erosity can be stretched to the breaking point.
In fact there has been a growing tendency toward
the adoption of paternalism in many respects, with
the result of increasing dependency and destroy-
ing initiative. The question arises as to where it
all will end if we keep on dipping into the public
treasury for the benefit of all sorts of enterprises,
good, bad and indifferent? The government al-
ready has a deficit, and that deficit is going to
grow with the passing years unless an already
over-burdened tax-paying public is called upon to
bear increased burdens of taxation. Already the
minority is paying for the support of the majority,
and this fact will be all the more impressive within
a few years. We seem to be encouraging the
development of a very large class of loafers and
shirkers who seemingly appear to think that the
world owes them a living and without effort on
their part to earn it, and in due course of time
that class is going to be a disturbing element in
our body politic that will be hard to reckon with.
The disabled World War veterans deserve and
should have generous treatment, but there are
thousands of World War veterans who are getting
far more than they deserve as compared to other
people equaly as deserving. A tremendous bur-
den is being borne, and it is getting heavier every
day. It is not confined to soldiers’ bonus and
pension and care of disabled veterans, which in
reality is a minor part of the burden, but it takes
in all kinds of benevolences and perquisites estab-
lished through various specious pleas as to neces-
sity or advisability, and all requiring enormous
drains upon the public treasury. We long since
have forgotten anything about prudence, thrift
and economy, but seem to be “hell-bent for elec-
tion’’ in our efforts to show how inconsistent and
unreasonable can be our extravagances. Where
will it end? There certainly must come a day of
reckoning.
We are beginning to agree with Henry Ford
that the way to cure our economic ills is to help
people to work and not to shirk. It is nothing
short of a crime to donate so extravagantly and
extensively as we do now, a practice that breeds
dependency and pauperism and adds to the gen-
eral spirit of unrest and dissatisfaction.
MEDICAL COWARDS
(Editorial, Jour. Indiana Med. Assoc-., May 1931.)
The average physician is a moral coward. He
is afraid that his practice will suffer if he takes
an honest and much-needed stand in opposition
to some of the things in his community that are
in every way detrimental to the interests of the
people, especially as concerns their health. The
richest man in the town can own insanitary and
disease-breeding rental property; the leading
newspaper can carry all sorts of fraudulent med-
ical advertising and publicly uphold medical
quacks; the leading preachers may solicit patron-
age for quacks and members of pseudomedical
cults; the bankers may defy quarantine and other
health regulations: the public school teachers may
disseminate pernicious and false teaching concern-
ing- the value of smallpox and diphtheria preven-
tion: the Christian Scientists may be responsible
directly or indirectly for any number of prevent-
able deaths; and in fact there may be almost any
kind of inconsistent, unreasonable and highly det-
rimental things occurring in the community and
not a single physician will offer a word of protest.
Is it any wonder that health matters and even the
practice of medicine are getting under lay control
and dictation? How long will medical men con-
tinue to be prize examples of first-class cowards?
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
723
FUTURE OF SURGERY
(From the London Times, weekly edition,
July 16, 1931.)
The Royal College of Surgeons has entered, in
the words of its President, Lord Moynihan, on “a
new career". The laying of the foundation-stone
of the Buckston Browne Surgical Research Farm
at Downe was the first step in that career; the
final step may, perhaps, be the supersession of
surgery by methods which will obviate its use.
That at any rate is one of the ideals which the
college has set before it in embarking on studies
which have as their object a clearer knowledge of
the origins and processes of disease in the animal
body. The Buckston Browne Farm lies well with-
in the tradition of British medicine. Much of the
work of John Hunter was done at his farm at
Chiswick, and Jenner, Hunter’s pupil, achieved
on a farm a discovery which doubled the popula-
tion of Europe. That the Buckston Browne Farm
should be situated within a stone’s throw of the
house, where, during 40 years, Charles Darwin
thought and worked and wrote, is of good omen.
School Health Department
CLIPPINGS
Allen G. Ireland, M.D.,
Director of Physical and Health Education, State
Department of Public Instruction, Trenton, N. J.
“H. W. Hetherington, on examination of 1999
children, 5 to 16 years of age, in whom latent tuber-
culosis was shown by the tuberculosis test, and
by nodules and bronchial glands demonstrated by
x-rays, finds underweight of little if any value in
diagnosis.”
“According to the studies of Janet H. Clark, of
Johns Hopkins University, a child seated 15 ft.
from a north window transmitting ultraviolet rays
would get no more effect from such radiation in
20 hours than he would in 20 minutes from direct
sunlight in the open air at noon. The tests were
made in March, April and May.”
“In California, in 1924 there were 9424 cases of
small-pox, or 2.41 per 1 000 population. Among
students of the University of California, however,
there have been no cases since 1907, when satis-
factory evidence of immunity to the disease was
made a requirement for entrance. In Utah, where
there is no exclusion of unvaccinated children from
any school, the State University had a serious
small-pox epidemic in 1922. Out of 50 colleges
studied by Prof. Legge, of the University of Cali-
fornia, 25 require entrants to show evidence of
immunity.”
“In a hearing survey of the schools of San
Francisco, 8.7% of the pupils were found with a
loss of 9 points or more sensation units by the
audiometer, and 1.6% of the total number tested
were considered sufficiently deafened to need
training in lip reading.”
“In the special Study of Vision of School Chil-
dren, by Kempf, Jarman and Collins (Public
Health Report for July 6, 1928) 66% of the eyes
which read 20/20 or better, read 20/50 or worse
when a cycloplegic was used and nearly 20%
tested 20/100 or worse after cycloplegic. This em-
phasizes the need for observation of children as
to symptoms of the eye-strain rather than the use
of the Snellen card for testing. The investiga-
tors recommend that ‘any child with symptoms of
eye-strain should be sent to an eye physician for
examination even if able to read 20/20 on the
Snellen chart’. Only 2% of the children of 6 and
7 years were found to be myopic, but the percent-
age rose rapidly to 9% at 12 years. Such defec-
tives can be found by use of the Snellen test.’’
Communications
HOW FRENCH DENTISTS MET THE INSUR-
ANCE QUESTION
Continued from August Journal
(Second part of letter from the Committee on
Study of Dental Practice, H. E. Phillips,
D.D.S., Chairman.)
As this is written, France is the latest great
nation to adopt an extensive system of compulsory
health insurance involving all branches of the
medical profession. This law went into effect
October 1, 1930, but it had long been under con-
sideration.
When Alsace and Lorraine returned to France
they brought back the German system of health
insurance. In spite of the admitted defects of
the German system there was a demand that
health insurance be now extended to all of France.
The first law passed in 1928, being largely copied
from the German scheme, was so full of defects
that it raised a storm of protest, particularly from
the medical professions.
When the government suspended its operation
this gave an opportunity for a complete rewriting.
The physicians and dentists, as often under sim-
ilar conditions, had been caught largely unpre-
pared. But they now got busy in earnest and to
excellent effect.
The physicians raised a fund of over one mil-
lion francs (about $40,000), set about a thorough
analysis of insurance, formulated their demands
and adopted them at a great mass meeting and
then carefully laid out a campaign, which they
carried through to a successful conclusion, to se-
cure these demands.
Since the dentists were included in the law
from the beginning, they joined with the physi-
cians in support of the latter's demands and then
formulated their own program.
Such a fight calls for a strong professional as-
sociation. The French dental profession is divided
into stomatologists and dentists with different
educational standards, which previously had made
common effort difficult. How the emergency
caused them to forget their differences is re-
flected in these words taken from a circular issued
by the stomatologists.
“It is necessary for every practitioner
thoroughly to realize that any mistakes made
724
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
now will govern our destinies in the years to
come. * * * It is of paramount importance
at this moment that the individualistic spirit
in medicine give way to the collective spirit,
which alone will permit some defense against
the collectivities that are confronting us.”
There was a dentist and a physician who were
members of the Chamber of Deputies. From the
beginning each of these worked both within and
without the Chamber to push the following pro-
posals of the medical professions:
(1) Complete freedom of choice of practitioner.
(2) Legitimization of all professional associa-
tions entitled to deal with the insurance societies
by the national associations of the profession.
(3) Direct payment of all fees.
(4) Professional representation on all admin-
istrative bodies.
(5) Complete safeguarding of professional sec-
recy.
(6) No lay control of professional activities.
Every one of these provisions was written into
the law. The dental patient brings to his dentist
a letter of introduction from his insurance society;
the work is performed; the customary fee charged
and paid; the dentist then endorses the work done
upon the letter which the patient takes to his in-
surance society and collects the amount due him,
which in most cases is only a part of the fee.
For prosthetic work the insurance society must
first endorse the estimate of the dentist as to the
cost.
There are representatives of the medical pro-
fession not only on every administrative body, but
even on the governing committees of the insur-
ance societies.
Although the insurance societies had more than
6,000,000 members, nearly all voters, the medical
professions, purely by virtue of organization, su-
perior knowledge of the situation, and a well-
planned campaign won a victory so complete that
their German confreres have enviously congratu-
lated them on escaping the evils of the German
system. This victory was so complete that instead
of the enactment of the law being followed by
‘‘doctors’ strikes” as in other countries, the insur-
ance societies “struck” in many places and re-
fused to sign the uniform contracts presented by
the medical professions in accordance with the
law.
It may have been a trifle too complete a vic-
tory, since the insurance societies are now be-
seeching the politicians to amend the law to take
away some of the advantages gained by the physi-
cians and the dentists. Whatever may be the out-
come of this prospective fight, the medical pro-
fessions will, at least, for the first time have the
advantage which the societies have had under
every other system, in that they will be in pos-
session of the disputed territory and know exactly
how to battle for their professional privileges.
Committee on the Study of Dental Practice:
R. E. Denny, D.D.S.
H. .T. Leonard, D. D.S.
G. S. Millberry, D.D.S.
C. E. Rudolph, D.D.S.
H. E. Phillips, D.D.S., Chairman.
A. M. Simons, B.L., Research
N. Sinai, D.P.H., Adviser.
CONCERNING SALT-FREE DIET AND FOCAL
INFECTION
(A letter to the Editor, dated June 23, 1931, from
Dr. Harris A. Houghton, New York.)
To those who are not especially interested, it
may appear more or less gratuitous in attempting
to disinter a discussion which found climax in
an article by Dr. Frederick M. Allen, of Morris-
town (Further Comments on Attacks Against Salt
Free Diet, 27:126, 1930), appearing in the Journal
of the Medical Society of New Jersey nearly 19
months ago. Every clinician should make it his
business to keep abreast of the times by reading
good current medical literature. It has been my
lot to have slipped for some unaccountable reason.
I missed this individual addition to medical his-
tory, and did not see it until yesterday, when it
was accidentally encountered while looking for
something else. Therefore, even at this late date, I
am asking that the following be made a matter
of record.
You will agree with me that my interest is justi-
fied by the fact that the criticism voiced by Dr.
Allen was largely directed against an article by
Berger and Fineberg (The Effect of Sodium Chlor-
ide on Arterial Hypertension. Arch. Int. Med.,
44:531, 1929), in which I was correctly designated
as an active proponent of the low-salt regimen as
a part of the therapeutic indications in the man-
agement of hypertension.
To make the setting complete, it will be remem-
bered that Dr. Allen also had some comment con-
cerning an editorial which appeared in the Jour-
nal of the American Medical Association (The Salt
Free Regimen and Vascular Hypertension, J. A.
M. A., 93:1561, 1929). My own mental reactions
on reading this editorial must have been similar
to those of Dr. Allen’s. Stimulated thereby, I
wrote a signed letter asking that it be published
in the correspondence column of The Journal,
mildly protesting against its arbitrary tone and
lack of balance in selecting evidence in drawing
conclusions. Publication was declined with this
comment: “I do not believe that we would be war-
ranted in giving this matter space in The Journal.
.... Unfortunately, editors have to select the
material according to their judgment as to what
is correct for their readers. If they are wrong,
they invariably suffer for their mistakes.” The cor-
respondence which followed is interesting, but
must pass on to oblivion for lack of space. Dr.
Allen was wiser than I; he turned to your excel-
lent Journal.
My present purpose, however, is different than
would appear from the above. All of us who have
followed Dr. Allen’s distinguished career would
probably give him more credit for his brilliant
work in research medicine than he would claim
for himself. It may be said with assurance that
without the basic work which he did, and which
covered many years of difficult labor, the dis-
covery of insulin would have been materially de-
layed. Furthermore, I would like to go on record
as saying that I consider Dr. Allen’s original
lengthy article on the control of arterial hyper-
tension by the use of the salt free diet (Allen and
Sherrill: Journal of Metabolic Research, 2:429;
1922) a splendid piece of clinical research. It
failed to go over, in my opinion, because up to
within a short time, the mind accustomed to think-
ing in terms of pathology rather than perverted
physiology, was in control of this particular field
of medicine.
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
725
Therefore, there would be little criticism on my
paxt for his comments on the work of O Hare and
Walker, Berger and Fineberg or on the editorial
cited in the Journal of the American Medical
Association. The clinical facts are stated correctly,
the evidence can be reproduced at any time, and
the conclusions are warranted. The so-called ex-
periments of Berger and Fineberg indicate of
themselves that these distinguished Cleveland
clinicians are not fully acquainted with the physi-
ologic principles which operate in the field where
they attempt to interpret phenomena.
Consequently, we will pass all that, and tui n to
Dr. Allen)’ s closing paragraph, which I quote:
“I claim originally to have developed
the idea of salt restriction for hyperten-
sion without knowledge of the prior work
of the French school and to have been the
first to apply it accurately enough to con-
trol the gireat mass of hypertension
cases;” . ■ • •
This does not have to do with the proper dis-
tribution of credit for the introduction of the salt
free regimen in the treatment of hypertension m
the United States, but has to do with its concentra-
tion We may accept it without guile. Personally I
can ‘make no such claim. In 1909, I read the pro-
ceedings of the Kongress fur Innere Medizm, held
that year at Wiesbaden (Verh. d. 25 Kong. Inn.
Med., 1909, s. 43 et seq.), and immediately began
the practice of salt withdrawal in the treatment
of hypertension and nephritis. Results began to
appear which prior to that were impossible. The
technic of this diet is difficult but not prohibitively
so My own technic was not perfected to my satis-
faction until 1917 or 1918. I was assisted, m
working it out, considerably by Dr. Cyrus W .
Field of New York, who, as the war closed, was
connected with the Army Hospital for Officers at
Lakewood, New Jersey. My first paper on the
subject was published in the Medical Recor ,
March 18, 1922. The Medical Record went out
of business as an independent periodical with that
Salt withdrawal, or “dechlormization , foi t
nephritides was talked of in this country as early
as 1905 (Kelly and Fife; Miller and Billings.
Trans. Asso. Amer. Phys., Washington, D. C
May 16 and 17, 1905) following the publication of
papers in France by Widal and Javal in 1903 and
by Ambard and Beaugard the year following. It
cannot be fairly claimed that the application m
America of the dietary principles to hypertension
was made in literature until Dr. Allen himself, and
Dr. John H. Musser, of Philadelphia (m that or-
der), penned short clinical articles which appear-
ed in different journals and within a few weeks o
each other (Allen: Jour. Amer. Med. ^SS1°”9 J '
1920. Musser: N. Y. Med. Jour., 112:570, 1920). My
own effort of 1922 gave credit to both, and also at-
tempted to give some theoretic basis for this ra-
tional therapy; an attempt which Dr. Allen did
not make until' 1923. .
Dr. Allen’s article of 1923, which was his fi st
large effort along this line, generously gave
both Musser and me credit for previous communi-
cations. He was especially generous with me. So
we may accept, as stated, his statement quoted
above, especially as it is suitably provided with
limitations.
His second statement, however, is one whic i
interests me more:
“also, that nobody shared this view
ctt first.”
I realize now, after over 18 months in a more
or less cataleptic state, that Dr. Musser and I
are in the same class so far as Dr. Allen is con-
cerned. It sounds egocentric to openly and
brazenly class myself with Dr. Musser, but, Mr.
Editor, I didn’t do it first.
Dr. Allen feels very strongly on the subject of
the salt-free diet for hypertension, as I do. In
spite of opposition, he would like to see the
method of treatment popularized, as I would, that
many, instead of a few, who suffer from hyper-
tension may have opportunity to receive its bene-
fits. He rightfully calls attention to symptomatic
relief independent of the arithmetic of decline. But
Dr. Allen has paid little or no attention to the
eradication of focal infections, so far as I can
judge from his published work, whatever remarks
he may have made being couched in most general
terms. In my opinion, this part of the treatment
is quite as important as the exhibition of the
salt-free diet. Undoubtedly certain positive re-
sults can be achieved by use of the latter, but the
question of progression as well as symptoms is
involved in the former. I took up this side of the
question first in 1911, and began to write in the
Long Island Medical Journal in 1915. Strictly
speaking, the idea was not original, as it followed
the reading of Billings,’ original communication in
the Archives of Internal Medicine (1910) on the
subject of the relation of focal infections to the
nephritides. Nor am I inclined to make it an ex-
clusive step, for a good many good minds in
medicine must have been ready for it.
Likewise, now that 20 or more years _ have
passed, a lot of good minds harbor theoretic be-
liefs but fail to put into practice that which ex-
perimental and scientific medicine have placed at
their disposal. The practice is difficult, more diffi-
cult than the proper exhibition of the low salt
diet. The difficulties, however, are not entirely
insurmountable, except in individual cases, and
the rewards to the patients are very great. I am
living in hopes that Dr. Allen will eventually lay
the weight of his standing and positive in-
dividuality on the side of the removal of focal in-
fections in the routine treatment of hypertension,
for they or syphilis, one or both, are always there.
I can assure those who are interested that this
phase of the subject is worthy of a life time of
study and experience.
Very truly yours,
Harris A. Houghton, M.D.
DEFENSE AGAINST MALPRACTICE SUITS
(An item contributed by Dr. Christopher C. Beling,
Chairman of the Special Committee
on Medical Defense.)
One of the most common causes mentioned in
malpractice suits is embodied in the complaint
that a fracture or dislocation has been impropei ly
treated. Reviewing a large number of such claims
we note a peculiar disregard of natural safeguards
which one would expect a physician to keep in
mind when treating such patients. For instance,
claim reports show the prevalence of the follow-
ing factors:
(1) No radiograph was made.
(2) Radiograph was made but, apparently, was
not consulted again during treatment.
(3) Radiography was used to diagnose condi-
tion, but not to show7 result of treatment.
726
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
(4) Physician relied too much upon his sense
of touch.
(5) No satisfactory examination made after
fracture had been supposedly set.
(6) Plaster cast applied on day of injury was
not again examined or removed until bones were
presumably united.
(7) Patient was not properly instructed as to
the danger of moving the limb or twisting the
cast which had been applied.
(8) In many cases, the physician had made no
detailed record of examination or treatment.
Furthermore, we find that physicians not in-
frequently show a considerable disregard of their
own interests, with reference to radiographs and
consultations:
(1) Some care should be exercised in the giv-
ing of x-ray pictures to patients or to their at-
torneys.
(2) Hospital officials, interns and nurses should
be instructed not to exhibit radiographs or records
to patients, or to other persons, without special
permission of the attending physician.
(3) Whenever there is “trouble in the air”, or
one is doubtful about his results, a specialist
should be brought into consultation; as double
checking is a factor of safety.
Typical Case. From the records we offer the
following example: A physician in one of our
counties telephoned for a specialist to assist him
in a troublesome case of wrist injury. There had
been an oversight or a wrong diagnosis from a
ladiograph, and necessity for an operation had
arisen. The original radiograph had been given
to an attorney, without the physician’s knowledge
and consent. The picture disclosed, definitely, a
fracture which should have been set — and an
operation avoided. Settlement of the suit cost
*3000. The patient has more than 25% permanent
disability.
This simple relation of facts tells an interest-
ing story, and suggests to all physicians dealing
with fractures and dislocations the necessity for
great care in all the details of that work, and in
the protection of themselves; for the major pro-
portion of malpractice suits arises from the treat-
ment rendered such patients.
Woman’s Auxiliary
A TASK PROPOSED FOR THE AUXILIARY
The Editor of this Journal being one of those
hay-fever victims who is rendered utterly useless
and helpless during the months of August and
September each year by the pollen polluted air,
everywhere in these eastern states, and who is
virtually compelled to seek refuge in the high
Rocky Mountains, high Sierra Mountains, or an
ocean voyage, was much impressed by a report
°f a Oman’s Auxiliary Campaign to Eradicate
Weeds in El Paso, Texas. Being at the same
time mindful of the fact that many of our own
County Medical Society Auxiliaries have been ask-
ing foi something to do”, we reproduce herewith,
from the Southwestern Medical Journal of June
1931, the full report of what El Paso women have
lone toward relief of hay-fever and asthma *if-
terers, and respectfully suggest that here is one
answer to that often repeated question. For-
tunately it is a task suitable for adoption by each
and every county organization.
EL PASO’S HISTORY OF WEED ERADICA-
TION RELATIVE TO HAY-FEVER
Mrs. J. A. Rawlings,
' hairman of the Weed Eradication Committee of
the Woman’s Auxiliary to the El Paso County
Medical Society, El Paso, Texas.
Russia, the most talked-of country today, has
unconsciously succeded in putting over on our
country one of its worst pests— the tumble weed--
which is the “Russian thistle”. The story goes that
in a shipment of grain from Russia was a new
kind of seed; some of the grain was sown in New
Jersey, and there appeared the Russian thistle
which grew rapidly and, like a huge ball, has
tumbled its way from the Atlantic to the Pacific
Hay-fever is everywhere prevalent as never be-
fore, due largely to this and many other weeds
plants and grains, which give forth pollen.
Two medical experts, after a survey of El Paso
said that 80% of the hay-fever here could be
prevented if tumble weed, and pig or careless weed
were eradicated, the former prevalent from May
till frost, the latter from August to frost. Earlier
in the season, the pollen from cottonwood trees
causes trouble; also pollinating Bermuda grass
The nimble weed is our worst offender in the
early summer. In appearance it is very attractive:
no hard prickers when small; it starts with a tap
loot producing tiny pointed branches, the size of
the lead in a pencil, and of a grey-green color
that deepens with age. It branches irregularly,
resembling the sprengenic fern; it grows to be a
huge bush, 3 to 5 feet high, becoming round and
brown in the fall. The wind severs its tap root
and it begins its tumbling journey, scattering
thousands of seeds. It has been estimated that
an average tumble weed matures 40,000 seeds.
Think how much public health work you do when
you pull one weed. Its mission is to produce pol-
len readily carried through the air, and therefore
readily causing hay-fever. A disease so common
we think of it as we • do a cold, but a most dis-
tressing disease producing real suffering; it causes
a feeling of depression that makes life seem not
worth the living. Hay-fever lessens resistance
and depletes the system so that other diseases fol-
low. Little children are among the greatest suf-
terers. An attack may begin early in the spring
and last till frost. One often becomes totally un-
fit for work.
In 1924, the El Paso Herald advocated a weed
eradication campaign. In March 1927, Dr. George
Turner talked before the Woman’s Auxiliary to
the El Paso County Medical Society on the cause
of hay-fever and its menace health. He stated
that he had talked before every organization in
town and had not yet succeeded in getting any-
thing done. It was determined to do something.
The newly installed president, working through
her strong executive committee, appointed speak-
ers to talk before all organizations of men and
women jiossible, explaining the need for weed
eradication, and the 89 members of the Woman’s
Auxiliary asked people in the homes to free their
yards from weeds and to clean vacant property.
The response was gratifying. The school children
were asked to pull tumble weeds and rewards were
offered. In 3 days 250,000 weeds had to be paid
for and we were forced to pay our debts with
public contributions.
Mr. H. D. Slater, Editor of the Herald, put on
a fine publicity campaign, designating one of his
best writers to the job. The result was excellent.
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
727
In fact, the articles attracted the attention of our
President of the Woman’s Auxiliary to the State
Medical Society and she had her secretary send
clipping's to the various medical auxiliaries in
Texas. We succeeded in getting the cooperation
of the El Paso County Medical Society, the Cham-
ber of Commerce, the Board of Health, the city
schools, the railroads and the many organizations
of the press. Representatives from the above or-
ganizations, together with those from 18 women’s
organizations, were asked to meet with the City
Council. Our Mayor, Mr. Thompson, saw the
need for weed eradication and did all in his power.
There was no budget.
The various departments cooperated. Dr. Mc-
Carnant, for the El Paso County Medical Society,
proposed an ordinance sponsored by Drs. Rawlings
and Brown, of the Board of Health, to fine prop-
erty owners who did not clean lots. In 1929 an-
other ordinance was passed taxing property, and
that is now in force. There was a splendid spirit
of cooperation and Dr. Outlaw, City Health Officer,
put through a fine piece of work.
Favored by dry weather and cleaning of tumble
weeds there was very , little hay-fever till August,
when much rain brought forth the careless or
pig weed in great profusion and there was much
suffering. This weed has various names and came
from Europe to Canada and the United States. In
1928 the City Council budgeted $1200 for weed
eradication. In April the Woman’s Auxiliary
asked cooperation of the City and Health Depart-
ments to put on a short educational campaign.
The city property was pretty well cleaned in the
early summer but the $1200 did not last through
the season. Those not afflicted with hay-fever did
not see themselves as “their brother’s keeper”. In
August the pig or careless weed became rampant
and there was such a flood of hay-fever that there
were thousands of cases; those who could, left
town, some not to return. The following year
(1929) the budget was increased by $1000 and the
city offered to clean property at $1 per lot. Many
sent checks; 5000 lots were cleaned. Real estate
men and railroads cooperated.
This last year, 1930, the work was better or-
ganized with a Weed Eradication /Department.
The weather was dry and the combination was
like preventive medicine. Few people got hay-
fever. As usual, the rains brought forth the pig
or careless weeds and they were cut. For the first
time the city had the appearance of being cared
for, though not half of the lots were free from
weeds. Example has been a strong influence in
homes. A lady said she was the first to clean
her place of weeds; the next year 2 did likewise
and now the whole block is beautifully kept. We
are proud of the last year's report; over 10,000
lots were cleaned. It shows fine cooperation and
work. To Dr. Outlaw great credit is due. The
press has shown the finest spirit of helpfulness.
Dr. Turner reports that since this work on weed
eradication not only are there fewer cases but
they have been less severe and where asthma was
frequent it is now rare. This year promises the
most luxuriant crop of hay-fever weeds ever
known; already many people are afflicted. The
weed eradication department is doing fine work.
Notices have been sent to nearly all vacant prop-
erty owners and many checks received to pay city
for cleaning lots. Many people are cleaning their
own property. The city has 25 men working
every day on city property and vacant lots. A
big factor now is the pollinating Bermuda grass
in the yards of residences, and a notice is being'
distributed by the Boy Scouts, reading:
‘‘Personal Notice Weed Eradication
The Mayor of El Paso and the Board of Health,
with the help of the Woman's Auxiliary to the El
Paso County Medical Society, which for the past 5
years have stressed weed eradication and through
the cooperation of the Boy Scouts of America, do
hereby give notice that, in accordance with an or-
dinance passed by The City Council on May 9, 1929,
owners and occupants of real estate are required
to eradicate and destroy liay-fever weeds, notably
tumble, pig and careless weeds and to cut Ber-
muda grass often enough to prevent seeding. Good
citizens do not have to be compelled to obey city
ordinances. This notice is handed to you in the
interest of several thousands of hay-fever suf-
ferers in El Paso. The Heqlth Department reports
that 20% of our population suffers from hay-fever;
not only adults, but children. One’s efficiency is
cut from 15% to 50%; sometimes totally. lrou can
greatly aid in reducing this suffering by cooperat-
ing. If everyone occupying or owning property
will attend to its need the problem is solved. Prove
your loyalty to El Paso and help make your city
clean and healthful.”
The Mesilla Agricultural College is now experi-
menting by spraying weeds. We tried burning but
now our faith is in the man with the hoe and the
Fire Department burns the pile. The Woman s
Auxiliary has a standing committee of 15 to as-
sist in every way possible with this work. Re-
cently a talk was given over the radio by a mem-
ber. This is a big problem but much progress
has been made, and this year promises greater co-
operation.
Some citizens are making contributions to poppy
seed. The Garden Club and Woman’s Department
of the Chamber of Commerce are planning to
beautify the vacant lots. Just as a home, by its
cleanliness and beauty, reflects the character and
ideals of those who live there, so a city, by its
cleanliness and beauty, reflects the characteristics
and ideals of its citizens. We hope in time to
have the most beautiful and cleanest city in the
Southwest.
Union County
Reported by Mrs. C. A. Hoffman
The regular meeting of the Woman’s Auxiliary
to the Union County Medical Society was held at
Bonnie Burn Sanatorium at Scotch Plains on July
8. The roll call showed a 'very small attendance,
only 8 members being present. Minutes of the
last meeting were read and approved.
As Treasurer McEihinney was absent, her report
was omitted. Reports from various committees
were called for. Report of special meeting and
dinner, held at the Watch ung Valley Club, Plain-
field, May 27, was read by Mrs. R. A. Gregory. It
was moved and seconded that the Treasurer pay
a deficit of $5.40. It was moved and seconded that
a comhiittee of 2 be appointed to confer with the
Treasurer regarding the sending out of notices
for annual and past dues. These notices to be
sent out periodically. It was moved and seconded
that Mrs. N. Currie and Mrs. W. Hallock confer
with Dr. Bensley, of Summit, and Dr. Laird, of
Westfield, suggesting that the county medical so-
ciety present to its members a number of good
reasons why the wives of doctors should be mem-
bers of the Woman’s Auxiliary.
728
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
Delegates' reports from the Woman's Auxiliary
to the New Jersey Medical Society Convention,
held at Asbury Park, and the Woman's Auxiliary
to the American Medical Association Convention,
held in Philadelphia, in June, were presented by
Mrs. Hubbard.
The Nominating Committee, consisting of Mrs.
E. A. Kinch, of Westfield, Mrs. Harold Johnson.
Plainfield, and Mrs. D. McElhinney, of Elizabeth,
was announced by Mrs. Hubbard.
It was moved and seconded that the Treasurer
and Corresponding Secretary be authorized to se-
cure a card index for paid-up members.
Informal discussion followed.
It was moved and seconded that meetings be ad-
journed until October.
County Society Reports
ATLANTIC COUNTY
Atlantic City Hospital Staff
Joseph H. Marcus M.D., Secretary
The meeting of the General Staff of the Atlantic
City Hospital Staff was called to order July 24, at
8.45 p. m., by President Milton S. Ireland. The
minutes of the previous meeting were read and
approved as read.
The scientific program was presented by Dr-
Joseph H. Marcus:
Epidermidolysis Bullosa Hereditaria. David
Smeethy, aged 3 years. Chief complaints: blisters,
since the age of 3 months; the slightest bruise
turns to a water blister; is nervous, has poor ap-
petite, cries, head sweats at night, photophobia, in-
somnia, tears and bites hands, rubs face with
hands; bleb appeared on heel at 3 weeks of age.
Epidermidolysis bullosa: Synonyms— epidermo-
lysis bullosa hereditaria; acantholysis bullosa.
Definition. An exceedingly rare, congenital
tendency to vesicle and bullae formation of any
part of the integument subjected to any form or
degree of traumatism.
Symptoms. The disorder is a rare one, and was
first described by Goldschieder in 1882. In the
vast majority of instances the presence of the
condition is first noted in early infancy, although
occasionally it does not develop, or at least be-
come apparent, until later in life. The lesions
consist of vesicles and bullae of various sizes
which develop as a result of even slight pressure
or irritation. They are usually filled with serum,
but may contain blood.
Etiology. The malady is decidedly hereditary
in character; most of the cases, with the excep-
tion of a few of the acquired form, giving a his-
tory of occurrence in one or several of the off-
spring of several generations. As mentioned,
trauma is the exciting cause. As yet, no other
factors are accepted. That the disorder is an
angioneurosis of hereditary origin is perhaps the
most logical explanation.
Treatment is purely symptomatic with a spe-
cial care in the treatment of blebs. The neuro-
therapy type is a combination of calcium lactate
para thyroid. The differential diagnosis at times
resolves itself in acrodynia, pemphigus, pellagra.
Prognosis. The condition usually continues
throughout lifetime, although frequently with
advancing years the tendency becomes less pro-
nounced.
Dr. William J. Carrington presented his re-
port of the Gynecologic Service for December
1930, January, February and March 1931, as fol-
lows:
During the 4 -month period covered by this
report there were admitted to 5A 129 patients, an
average somewhat over 1 a day. All were ex-
amined and studied; 18 of them did not need
operative interference, G who did declined and
signed releases, 22 were curetted for retained
secundines, 23 had gynecologic operations other
than laparotomies, and 64 were sectioned. There
were 48 consultations, mostly preoperative. There
were 2 deaths-
Cancer. Three cancer patients were ad-
mitted, 1 with advanced carcinoma of the vulva;
the hemorrhage and sloughing were temporarily
controlled with figuration; two received radium,
1, 1920 and the other, 5680 mg. hr. It has been
5 years since we have operated upon a carcinoma
of the uterus.
Fibroids. Three myomectomies were done and
22 hysterectomies; 1 tube and ovary were saved
in patients under 40 where possible.
Appendectomies. Prophylactic appendectomies
were done in 38 of the 64 laparotomies.
Fibrosis Uteri. In 2 cases of fibrosis the bleed-
ing was controlled with 960 mg. hr. of radium.
Ovaries. There were 29 bilateral and 8 uni-
lateral oophorectomies. There was 1 chocolate
cyst, 1 dermoid cyst. 12 poly cysts, and the re-
mainder were removed either in patients over
4 0 who had hysterectomies, or in women with
pyosalpinx.
Fallopian Tubes. Two were resected : 1 was
injected with 3 c.c. of 10% argyrol in a young
girl whose other tube was hopelessly de-
stroyed by gonococci. In all there were 12 uni-
lateral and 29 bilateral salpingectomies. In 1
case of chronic asthma the patient was sterilized
by partial excision of the tubes.
Displacements. One Gillian and 2 Montgomery
operations were performed for retrodisplacement.
Broad TAgament Cyst. One huge suppurating
broad ligament cyst was erupted and packed, no
attempt being made to excise the walls of the sac.
Adhesion s were released in 1 case. The pre-
operative diagnosis of pyosalpinx was wrong, else
we would not have operated. She probably has
more adhesions now than before operation.
Ectopic Gestation. One patient was admitted
and operated upon.
Cesarean Section. Three were done — 2 for con-
tracted pelvis, and 1 by mistake. We thought it
was a soft fibroid. The fetus had been dead and
there was no amenorrhea.
Omental Tumor. What we took to be a dermoid
of the right ovary turned out to be an orange-
sized inflammatory mass of omentum with no
other pelvic pathology.
Fistula. One ureterocervical fistula appear-
ed 10 days after a difficult hysterectomy. It
was doubtless caused by a deep suture which
caught the ureter. It opened and closed several
times before finally healing spontaneously.
Cystocel e. Four anterior colporrhaphies and 2
Watkins-Wertheim interposition operations were
done.
Rectoce.lc. Nine perineorrhaphies were per-
formed.
Polypi. There were 4 polypectomies.
Cervix. The cervix was cauterized twice, 4
Sturmdorf amputations, 1 double flap operation
and 1 trachelorrhaphy were done.
Sebaceous Cysts. One patient had multiple
sebaceous cysts of the perineum. These were
excised.
Sept., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
729
D and C. There were 2 diagnostic curette-
ments and 15 curettements in connection with re-
pair operations.
Bartholmectomy was done twice.
Cystoscopy. Six cystoscopic examinations were
made.
Abortions. There were 2 therapeutic abor-
tions, 1 for nephritis under spinal anesthesia, and
1 under nitrous oxide for pulmonary tuberculosis;
4 complete abortions were discharged without
operation; 22 incomplete abortions were dilated,
where necessary, lightly curetted and tightly
packed. This method is frowned upon by a num-
ber of leading gynecologists who prefer to let the
placental fragments rot out, unless there is vio-
lent hemorrhage, lest the meddlesome curet
break down the protective inflammatory zone- If
watchful waiting is to be employed let us use it at
home and not deprive needy cases of our all
too few gynecologic beds. None of these curet-
tements had any complications whatever, and
their average stay in the hospital was less than
4 days. Of these 22 incomplete abortions 2 were
colored and 20 were white; 11, exactly half, were
Atlantic City women; 22 incomplete abortions is
the smallest number in years. We are proud of
this decrease. In the not dim distant past our
ward was the happy hunting ground for retained
secundines, a port of refuge and refuse for the
abortionists of South Jersey and Philadelphia.
We were over-run to the exclusion of most every-
thing else. Not so this year. Why? It is un-
likely that the depression has had anything to
do with it, and there is no amenorrheic morato-
rium. But the real reasons, I think, are the in-
creasing knowledge and use of contraceptives
and no abortionists nearer than Wildwood or
Cape May.
In connection with the subject, some of you
know that Soviet Russia legalized abortions in
November 1920- Oh, there were abortions in
Russia under the Czar. Reputable physicians
produced prophylactic abortions for medical rea-
sons, as we do here. But the rich employed skill-
ed but unscrupulous specialists, and the poor
were left to ignorant, dirty midwives. After the
revolution, Soviet Russia attempted to care for
all alike and legalized abortion. Any Russian
woman can request an abortion at any govern-
ment hospital. These abortaries are scattered all
over the country. Boyko, of Kharkov, studied
the results after 10 years and reports that the
reasons for abortions in the Soviet Union were
as follows: (1) Illness, 21.6%; (2) nursing a
baby, 6.8%; (3) desire not to have a child, 28%;
(4) poor economic conditions, 48%; (5) desire
to hide pregnancy, (a) in small towns, 4.1%; (b)
in large towns, 0.5%.
Now, while abortion is accessible to every
Russian woman, there are some interesting reg-
ulations: (1) The time limit is 3 months, if the
indications are social. (2) Repeated abortions
are forbidden closer than 6 months apart. (3)
The patient must stay in bed 3 days. (4) Fin-
ally, the Soviet law requires that to every woman
who applies the danger must be explained.
As might be expected, the legislation on abor-
tion in Russia met with a flood of criticism from
the other countries of the world. It was claimed
that Russia would degenerate. But Boyko states
that the birth rate under the Soviet rule is the
same as under the Czars, approximately 4%,
while in France it is 1.3%, and in England 3.4%.
The total increase in population in Russia is 3,-
500,000 a year-
Deaths. There were 2 deaths during the
service. The first of these was preventable. E.
C., colored, aged 33, without children. She had
a tender frozen pelvis. Preoperative diagnosis
was bilateral pus tube with a small uterine fi-
broid on the left side of the uterus. Her Wasser-
mann and Kahn were negative, her hemoglobin
was only 50%, and she had a little fever, 99.4, and
most significant of all her blood sedimentation
test showed marked activity. However, the medi-
cal chief reported her heart and lungs all right.
Her urinalysis before operation was negative,
and her P. S. P. was 35%-(-25%, or 60% — 2
hours. Her leukocytes were only 9 750 and her
temperature did not flare up after several vigor-
ous bimanual examinations. iSo we decided to
operate in spite of her low hemoglobin, and her
marked blood sedimentation activity.
We found bilateral pyosalpinx all right, but
the mass we took, to be a small fibroid on the left
side was a dermoid cyst of the ovary. The opera-
tion, a bilateral salpingo-oophorectomy and ap-
pendectomy, was done under nitrous oxide-ether,
and was not difficult or tedious. But the next
day her temperature went up to 103; her pulse
was 150, weak and thready, and her respiration
varied between 5 0 and 70- Her chest remained
clear, but her kidneys shut down and the 20 oz.
obtained showed 40 mgm. % of albumin, and
numerous hyaline, and fine and coarse granular
casts. In spite of the usual preagonal therapeu-
tic activity, she died 2 days after operation. This
fussing included digitalis, caffein, adrenalin,
morphin and atrophin, saline and glucose, an
ice bag to the precordium, and Locke Ringer by
Murphy drip. She should not have been oper-
ated upon. Had I paid heed to her sedimenta-
tion test I would have postponed operation un-
til she had established immunity. This I thought
she had done. But the absence of fever, the ab-
sence of leukocytosis, the absence of a flare up
after bimanual examination are not enough. The
diagnosis of established pelvic immunity rests
not upon 3, but upon 4, cardinal symptoms- All
of them must be right if we are not to subject
our patients to unnecessary risks. This case is
a never to be forgotten illustration of the value
of the blood sedimentation test.
The other death will be reported by Dr. Uzzell.
Ruptured Uterus. , One of our most inter-
esting cases was that of a spontaneous rup-
ture of the uterus during labor, without manip-
ulation, pituitrin, ergot or quinin, and without
previous cesarean section. The patient was a
healthy white woman, 31 years of age, with a
large baby, presenting the breech at 42 weeks
of pregnancy. She had 1 child born 6 years ago
without the slightest difficulty. Ten years ago
she had an appendectomy but there was no path-
ology of the uterus or adnexa. After 10 hours
of active labor this time the cervix was tight
and rigid- The baby was large and breech pre-
sented. The abdominal tumor seemed to be di-
vided at the level of the umbilicus by a ridge,
the ring of Bandl. After consultation, a section
revealed an oblique, jagged rent in the lower
uterine segment. The contents of the uterus had
not escaped into the peritoneal cavity, but the
left uterine artery was torn and the anterior and
posterior layers of both broad ligaments were
separated by a hematoma, a distance of 3 in. In
oblique, jagged tears hysterectomy is the opera-
tion of choice, but the condition of the woman
and the mechanical difficulties were such that
the baby and placenta were removed and the tear
730
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Sept., 1931
sutured. Convalescence was placid and recovery
complete and uneventful.
Rupture of the uterus is uncommon. Scheyer
reports 12 cases in 11,300 confinements. But they
were all due to pituitrin administered in , the
second stage of labor, or to the separation of a
previous cesarean scar. In past years I have
had 2 cases where the cicatrix gave way. Both
had been operated upon by good men. How-
ever, it is likely that the sutures at the original
section were drawn so tight that ischemia re-
sulted, and scar tissue was formed.
To those of us with excellent hospital facilities
available, any treatment for rupture of the
uterus other than immediate laparotomy is un-
thinkable. Yet Klein reports 149 ruptures treat-
ed surgically with a mortality of 44%, and 198
cases treated conservatively, by packing from be-
low with a mortality of 32%. Klein states that
packing causes less trauma, and can be done
quickly, at home, with less skill.*
Mendenhall made the diagnosis of ruptured
uterus with the head down. He delivered quick-
ly with forceps, explored the uterus with his
hand, found that the placenta had escaped, dis-
covered it among the coils of intestines, brought
it down and packed, because the patient was
pulseless. He gave her a transfusion and re-
covery was prompt and complete.
In connection with pituitrin, some of you may
not be familiar with Hoehne’s sign of rupture of
the uterus. The sign is the complete absence of
uterine contractions after repeated injection of
pituitrin- A poor sign, if you ask me, but
Lazarevic had a case of atypical rupture with-
out shock or other signs save Hoehne’s. The
rupture was 12 cm. long through which the pla-
centa and half of a large baby had been ex-
truded into the abdomen.
After an exhaustive search through the litera-
ture, I have been able to find but one reference
to a spontaneous rupture of the uterus during
labor. Dr. Rojas, of Buenos Aires, had a case in
a woman of 20 who had a neglected shoulder pre-
sentation. As in our case, there had been an ap-
pendectomy.
The recovery of our patient was due in part
to the suppression of the desire to do a hyster-
ectomy, and in part to prompt interference. She
could not have long survived with her uterine
artery pumping away as it was. After an hour
or 2 most of them die, yet Grosse reports a re-
covery with operation 12 hours after rupture-
The cooperation of the superintendent, the
staff, the laboratory and the nurses was excellent.
Again this year we were not satisfied merely to
make a preoperative diagnosis. The intern, the
chief resident, the associate and the chief had to
record in black and white their preoperative
diagnoses. The living pathology varied so wide-
ly at times from our preoperative diagnosis that
it was hard to remain nonchalant. But all of
us learned more from our mistakes than from
our successes.
Dr. Edward TJzzell presented a case reported
from the service of Dr. William J. Carrington.
Dr. Samuel Barbash, Chairman of the Com-
mittee on “Investigation of Digitalis Preparations
for Hospital Usage’’, submitted his report as fol-
lows: A recommendation that the following prep-
arations be used in hospital routine and so elim-
inate the accumulation of large number of va-
rious preparations of digitalis carried in the
pharmacy of the hospital: (1) Standardized
tincture of digitalis; (2) tablets of powdered
leaf; (3) digitan for hypodermic use.
Following a general discussion by the mem-
bers present, the meeting was adjourned and,
shortly following, the Major Staff convened.
Obituaries
DAVIS, Lester R., died July 13, 1931, at his
home, 59 Chancellor Avenue, Newark, from heart
disease. He was on the staff of the Presbyterian
and St. James,' hospitals and was a member of
several fraternal organizations. He was in his
forty-eighth year.
Dr. Davis was the son of the late Lester Davis,
of Elizabeth, who was president of the Elizabeth-
port Bank. He was graduated from Pingry School
in Elizabeth and the University of Pennsylvania,
After completing his medical work, he went to
Newark, where he had practiced since.
He was a member of Salaam Temple and of the
Jr. O. U. A. M. He also was a vestryman of St.
Stephen’s Episcopal Church in Newark. Besides
his general practice, he served as physician for
The Celluloid Company of Newark.
Dr. Davis leaves his wife and a daughter, Mrs.
Quentin Ferris, of Chicago.
GARRISON, Biddle H., M.D., an outstanding
Monmouth county surgeon, died at his home Sun-
day, August 30, 1931, from complications of heart
and kidney ailments. He was 53 years old.
Dr. Garrison was chief of staff at the Ann May
Hospital in the county.
He graduated from the Hahnemann Medical
College, Philadelphia, in 1898, and began his prac-
tice in Red Bank in 1901.
Surviving him are his widow and one son, Biddle
H. Garrison, Jr. Funeral services were held Wed-
nesday, September 2. Burial took place at Dr.
Garrison’s birthplace, Elmer, N. J.
LOCKWOOD, Frank Wesley, one of the leading
physicians in the Oranges until his retirement last
October, died August 9, 1931, at his home, 43
Woodland Avenue, East Orange. He had been in
failing health several months.
Dr. Lockwood was East Orange’s city physician
from 1905 until 1913 and when he retired was one
of the 2 active original members of the staff of
St. Mary’s Hospital. Orange. He at one time was
the hospital’s chief of staff.
Born in Kingsland, 59 years ago, Dr. Lockwood
practiced in the Oranges 35 years, specializing in
surgery, although he was a general practitioner.
He was graduated from the College of Physicians
and Surgeons of Baltimore in 1893. Dr. Lockwood
lived in Bloomfield before going to East Orange.
He held memberships in Orange Mountain Medi-
cal Society, William Pierson Medical Library As-
sociation, New Jersey Society of Surgeons. New
Jersey Medical Society and the American Medical
Association.
Surviving are his wife, Mrs. Clara H. Lockwood,
and 2 sons, Dr. Nelson W. Lockwood, of East
Orange, and Elmer K. Lockwood, of Newark.
VAN MATER. John H.. M.D.. of 9 Second Ave-
nue, Atlantic Highlands, New Jersey, died at his
home Wednesday, August 26, 1931. He was 74
years old.
Dr. Van Mater was a former Mayor and Mon-
mouth County Sheriff and practitioner here for 48
years.
731
J ournal of The Medical Society of New J ersey
Under the Direction
of the Committee on Publication
Vol. XXVIII.. No. 10 ORANGE, N. J., OCTOBER, 1931 Single Copies, 30 Cents
AN HISTORICAL SKETCH OF THE DE-
VELOPMENT OF PREVENTIVE
MEDICINE IN THE STATE
OF NEW JERSEY
T. Bennett Morrison, M.D.,
Newark, N. J.
It has been frequently stated that, if the
medical profession had been as deeply en-
grossed in the development of preventive
medicine as it has been in the cure of disease,
we would now be in the millenium of human
health and physical adaptation to our environ-
ment.
In this brief review, I have endeavored to
draw up a chronologic record of the efforts
of our profession in New Jersey in the de-
velopment of preventive medicine, to indicate
that, up until recent years, the general public
has lagged far behind and that the legislature
of our state has had to be urged and invoked,
in many instances for years and years, before
our repeated recommendations have been en-
acted into laws.
In 1766, there was formed in New Jersey
the first State Medical Society in America.
Dr. George H. Lathrope published recently
in this Journal a delightful paper outlining the
early days of medicine in the colony, and Dr.
E. C. Jackson has written a charming bio-
graphic sketch of the first President of the
State Society. It is sufficient for me to re-
cord that the Medical Society of New Jersey
was established for the betterment of the
health of the community and took the first
steps in preventive medicine.
The history of the early practice of medi-
cine, in the colony, was bound up with the
life work of the clergy. They were the min-
ister-doctors. Educated for the ministry in
European countries, they studied what was
then known of medicine, before coming to the
wilds of America, in order that they might
couple with the salvation of souls the salvage
of the human body in accident and disease.
In 1787, the Medical Society of New Jer-
sey wrote to the Massachusetts Medical So-
ciety acquainting that organization with the
origin, progress and existing state of the
Medical Society of New Jersey and inviting
it to enter into a correspondence in matters
relating to health and the cure of disease.
This is the first record of an attempt to reach
outside of the colony in an effort to supply
healing, comfort and guidance in health, to
the public. It is referred to at this moment
because it later led to introduction into New
Jersey of vaccination against smallpox, the
first real step in the colony toward preventive
medicine.
Dr. Burnett, President of the Society in
1786, in his Annual Address, said, in part:
“The great share of public confidence and
favor, and the countenance and support of
reputable and worthy characters of the state,
not undeservedly, I hope, yet almost beyond
expectation, affords the most flattering pros-
pect of great future utility. I hope, I trust
and believe, that by wise and prudent deport-
ment, you will, as a society and individually,
merit more and more the patronage and es-
teem of the public. All nostrums retained
and kept secret from avaricious motives, and
732
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
more especially puffed up for sale, are un-
worthy of the character of a physician. They
are dangerous to society, and I venture to say
have slain their thousands and tens of thou-
sands. What I mean is that you are to put
a helping hand to the great work of promot-
ing medical knowledge. You are to assist in
raising the noble, God-like art of healing to
the highest pitch of perfection.”
It is worthy to note that this evidently
competent and progressive physician advo-
cated the writing out of histories in all cases,
describing accurately the symptoms in the or-
der of their occurrence, observing the age and
constitution of the patient, the place — -evi-
dently the location — of the disease and the
state of the liver, together with the medicines
administered and their effects. He continues :
“This, I confess, requires great attention and
diligence, but would be attended with un-
speakable advantage, both to the patient and
the physician, abundantly sufficient to com-
pensate, and more than compensate, for all
the time and trouble.”
Our record of events will, as you will note,
be in large measure a record of the State
Medical Society and its officers. In 1788, the
President, Dr. Elmer, read a very valuable
dissertation on “The Qualities of Air”, and,
although the physicians of that date had not
as yet comprehended the benefits of pure air
and the part it played in respiration and
health, here was evidence of a groping in the
dark for what we so well know in these days,
aided as we are by the light of later scientific
discoveries.
In 1789, Dr. James Stratton made the first
reference in this country to influenza, ac-
curately describing the symptoms and re-
spiratory involvement.
In 1790, Dr. Griffiths, the President, read
a paper on “Pulmonary Consumption” in
which he said: “When a person happens for
a long time to remain in contact with another
laboring under this disease, the putrid miasma
in perspiration enters into his vessels, and,
as if by fermentation, assimilates his blood
into its own putrid nature.” It is not the pur-
pose of this paper to deal with the etiology or
prognosis of disease nor to discuss treatment
in this early period, but Dr. Griffiths was
probably in advance of his time, in conceding
the infectious nature of consumption although
he did not know the true method of spread
of the disease, and calling attention to its in-
fectious nature must have had a salutory ef-
fect.
In 1792, the President, Dr. Dunham, read
a very voluminous paper on “The Benefits of
Bathing”, as a preventive measure in medi-
cine. It is too long to quote here but it was
the first recorded dissertation on this valuable
adjunct to health ever brought to the atten-
tion of the physicians in the province.
While inoculation with the specific virus of
smallpox was extensively employed in the
New England States, following its introduc-
tion by Cotton Mather and Dr. Boylston in
the year 1721. and was rather extensively
used up to the year 1760, to produce a mild
form of the disease which far too frequently
proved fatal, it remained for a physician in
Nezv Jersey, so far as the recorded history
shows, to be the first physician in America
vaccinated against smallpox with kinepox vi-
rus. I am sorry I cannot find his name, but
he was a member of the Standing Committee
in after years, 1846, and that committee was
composed of Drs. A. L. Smith, W. T. Mer-
cer, and S. H. Pennington, all of Newark.
This physician had himself vaccinated in
1810, and it proved a protection through sev-
eral outbreaks of smallpox for at least 35
years. It was not until 1834, 45 years after
this first success in our country, and 58 years
after the announcement of Jenner’s masterly
work in smallpox vaccination, that a commit-
tee of the State Medical Society in New Jer-
sey urged the legislature to make vaccination
compulsory. It must have been extensively
employed in the interim, however, for back-
in 1829 the Standing Committee reported that
it had proved successful in every instance
where it had been tried.
In 1812, a committee of the State Medical
Society was formed to make a study of the
meteorologic conditions in the state. In 1820
the By-Laws of the Society provided for a
“standing committee to make a yearly survey
of the general health of the people, a study
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
733
of the climate, soil, ponds and streams, alti-
tude, forestry and the cause and cure of epi-
demics”.
The reports of these standing committees
were the direct forerunners of the request of
the Society, in later years, for establishment,
by the legislature, of state and local Boards
of Health. In 1829, a resolution was adopted
against the evils of the use of alcoholic bever-
ages. Then, as now, New Jersey was as wet as
the Atlantic Ocean and inebriety was having a
disastrous effect upon public health and mor-
als. The resolution reads as follows :
“Whereas, the vice of intemperance has be-
come an evil much to be deplored and threat-
ens in its progress to sap the foundations of
our civic and religious institutions ;
Be it resolved, That we at home and abroad
exert our influences to suspend the use of ar-
dent spirits in the ordinary associations and
avocations of our fellow citizens, believing
that of all the deviations from the paths of
duty, there are none which so forcibly im-
peach the intentions of men to the character
of rational beings as the inordinate use of
spirituous liqueurs. *****
Resolved, That, with a view to guarding
against a taste and contracting a habit of
drinking spirituous liqueurs, we will, as far as
the nature of the articles admit, prepare our
medicines with water as a menstruum instead
of spirits.”
In the same year the Medical Society claim-
ed to be the guardian of the health of the
state’s inhabitants. The following preamble
and resolution were presented at the annual
meeting :
“Whereas, The provisions in the supple-
ment of the Act of Incorporation of the
Medical Society of New Jersey, passed 1823,
the privilege of vending drugs and medicines
is extended to merchants and shopkeepers,
to the detriment of the profession, and more
especially to the imminent danger of the
health and lives of our citizens, inasmuch as
medicines of a spurious and bad quality are
often sold, and even when genuine, by per-
sons totally ignorant of their salutary or
deleterious properties, or of the quantity in
which they may be safely administered ;
therefore, be it
Resolved, That, as guardians of whatever
is connected with the subject of health, it is
incumbent upon the Medical Society to pre-
sent the subject to the consideration of the
legislature at its next sitting, and obtain, if
possible, a repeal of the provisions above re-
ferred to, or such modifications as shall ex-
clude all other regularly licensed physicians
from vending by dose or small quantity any
drugs principally used as a medicine.”
As the Medical Society was fighting to
maintain its very existence during the next
10 years, frequent and repeated attempts hav-
ing been made by enemies of the Society to
have the Act of Incorporation repealed, the
fate of the above resolution Was not recorded.
An epidemic of cholera spread over the en-
tire state in 1834-35. How earnestly the pro-
fession was groping in the dark for the cause
of this disease is shown in the report of Dr.
S. H. Pennington, a member of the standing
committee and one of the outstanding physi-
cians of the day. In the annual report of his
committee, he said: “Of the pathology of
this disease, your reporter fears that he can-
not furnish any information which will throw
additional light on this dark and mysterious
subject. The theory is not improbable which
refers the disease to an affection of the gang-
lionic system of nerves. The viscera, which
are chiefly affected, are those to which the
nerves of this system are mostly distributed,
and the symptoms are those which we might
expect from the suspension or diminution of
their energy. ***** I have not attempted
to argue the question of the contagious nature
of cholera in the above account. I have en-
deavored to present facts with some clearness
and fairness, in order that their bearing may
be at once seen. Some of the cases described
would, perhaps, strongly incline to that doc-
trine ; and those in Whippany, particularly,
would not seem capable of explanation in any
other way. Still, your reporter is not pre-
pared to admit the truth of the doctrine, be-
lieving he has found ample reason within his
own experience for thinking that, in numer-
ous instances, it does occur independently of
contagious influences.”
Reports of the standing committees over
this period of 50 years or more indicate the
734
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
most profound investigations as to the cause
of epidemics and, as the germ theory had not
vet been advanced, physicians were forced to
fall back on the doctrine of Hippocrates and
Boorhaave ; that the heavens, the seasons of
the year, the sun, the sea, the mountains,
lakes, rivers and marshes, vapors, exhalations
and meteors, etc., were the underlying causes
of disease.
From 1818 to 1834, the Medical Society of
New jersey gave its hearty support to the
movement for official publication of the
United States Pharmacopeia.
In the year 1837, Dr. L. A. Smith, the
President, read a paper before the Society
in which he urged the erection of an asylum
for the care of the insane, and a committee
was appointed, at his suggestion, to memori-
alize the legislature on that subject.
In 1853, a resolution was adopted at the
Annual Meeting of the Society that, in its
opinion, the sanitary laws of the state needed
revision, and a committee was appointed to
take up this matter with the legislature. Dis-
cussing the crying necessity for such revision,
the committee reported that it had made a
personal study of all laws relating to health
of the people of New Jersey from the time
of its organization into a government under
Lord John Berkeley, Sir George Carteret and
Sir Philip Carteret, up to the year 1853, as
follows: “The sum of the acts which have
been compiled reaches 174 but this does not
include a large number relating to the drain-
age of low and wet lands, which had a vast
influence on the health and longevity of the
inhabitants of the localities so drained. With
all due respect to the wisdom and understand-
ing of our forefathers, and of our legislatures
of the present day, your committee cannot but
regret that so much time has been taken up
with the more moneyed interests of the in-
habitants of New Jersey, to the almost total
neglect of those measures best calculated to
secure health and longevity. Such legislation
as this * * * * * is so short sighted we marvel
that more attention has not been directed to
it. Inasmuch as every year added to the life
of man, and every day saved from sickness,
is capital added to the resources of the state
equal in amount to the worth of the time
saved, the principal accumulating annuallv
and the interest yielding a handsome revenue.
If the interests of the state of New Jersey
required the enactment of 25 several laws
during the years from 1789 to 1848 regulat-
ing the oysters in our bays and harbors, sure-
ly the health and longevity of man is worth
the time to pass one efficient law for life
preservation.”
These opinions were written into our rec-
ords 78 years ago and yet one might think
he was reading the arguments of a statistician
of the Prudential or of the Metropolitan Life
Insurance Companies, or of the leaders of in-
dustry pleading with our legislature today for
the conservation of human health as an asset
to the state. The report continues : “It is to
be hoped that the influence of this Society
will be sufficient to induce the state to ap-
point a commission to examine into these
matters and draft such an Act as is called for
by the spirit of the age. In sanitary legisla-
tion,’ particular regard should be had for
school houses and work shops. Throughout
our state, children are collected in schools
that are too small and badly ventilated. It is
scarcely necessary to mention to the medical
profession the evils of overcrowding a great
number in a small space. Besides the usual
deterioration of the air by the mixture of non-
respirable air and gases, diseases are propa-
gated that, under the influence of better ven-
tilation. would be harmless. The size of the
school rooms, the number of scholars, the
ventilation and heating, should be regulated
by positive enactment. Every workshop in
the state should be under the supervision of
the sanitary law. Mill ponds and marshes
should be under the supervision of a health
officer. Protection against smallpox should
be absolutely required by law. In conclusion,
your committee would recommend that our
Society, through its officers, request the ap-
pointment of a commission to report at the
next or a subsequent sitting of the legisla-
ture.”
In 1855, Dr. A. B. Dayton, in a masterly
address before the legislature, urging the pas-
sage of certain amendments to the Medical
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
735
Practice Act, in which he referred to the high
motives of the medical profession, finished
his address in the following dignified words :
“But our motives may be impugned, we may
be accused of acting from selfishness or sor-
didness. ***** We claim to act from high-
er and loftier motives nowise akin to base in-
centives. Independently of these feelings as
physicians, we believe in the honor and dig-
nity of the profession and in the improve-
ment of the science essential to life and health.
We are anxious that our children and your
children and their children’s children shall
have the benefits of an educated medical
corps. ***** We come before you, gentle-
men, not as supplicants for personal or pro-
fessional favors. We ask nothing at your
hands that will not subserve the best interest
of your constituents and the world. Let this
be accomplished (referring to a proposed en-
actment to raise medical standards) and you
will fulfill the wishes of the Medical Society,
the profession and the people.”
In 1860, the standing committee recom-
mended the revision of the quarantine laws so
as to prevent the influx of disease from the
adjoining states of New York and Pennsyl-
vania. In 1862, the Standing Committee
recommended the grading of streets in towns
and villages. It scarcely seems possible that
only 70 years ago the streets in our smaller
towns and villages were ungraded. The com-
mittee also recommended that supervision of
the disposal of sewage be placed under legal
enactment so as to control many sources of
ill health. In 1860, the sinking of artesian
wells was advocated by the committee as a
protection of the potable water supply from
surface drainage. A few years later, as a re-
sult of years of labor and the presentation
of scientific facts to the city fathers of the
city of Camden, by Drs. Walter S. Bray and
Dowling Benjamin, artesian wells were sunk
for the entire potable water supply of that
city.
In 1862, referring to life among the pines
in southern New Jersey, the Standing Com-
mittee remarked that return to home by a
consumptive who had resided in the pines for
a short time was frequently followed by rapid
death. Might it not be worthy of thought,
whether a hospital, so regulated as to pre-
serve an equitable and moderate temperature
during the winter, within some appropriate
forest, would not furnish us with additional
means for prolonging life in an affection so
utterly hopeless as phthisis? And this state-
ment was made 44 years before the introduc-
tion of tuberculosis sanatoriums at Saranac.
During the period of 30 years from 1860-
1890, the medical profession in New Jersey
again and again urged the legislature to bring
about enactment of laws for the prevention
and control of disease through intelligent
sanitary supervision. With no thought of
emolument, sacrificing their own time and
personal interests, these forefathers of ours
in medicine were “a pillar of fire by night
and cloud by day”, leading the people of New
Jersey to a cleaner, more healthy land. No
history written in this state up to date gives
our profession the place it deserves in secur-
ing the adoption of a modern, scientific, sani-
tary code.
In 1863, the Standing Committed called at-
tention to the crying need for a hospital in
Newark, and one old practitioner remarked
that it was a pity that in a city with 50
churches there was not a single hospital.
Again, it does not seem possible that only 68
years ago, the life-time of a physician, our
cities and towns were without any hospital ac-
commodations. In 1866, the first hospital for
the care of the insane was erected at Tren-
ton. It had taken 29 years of almost con-
stant agitation on the part of our profession
to secure from the legislature, an appropria-
tion for this hospital.
We were under the impression that Dr.
Henry O. Reik and the writer deserved the
credit for advocating the formation of the
first Tristate Medical Conference, but it seems
that in this we were mistaken, for in the year
1866, Dr. Woodward, of Connecticut, ap-
peared before our State Society and pleaded
for an interchange of medical ideas. He evi-
dently journeyed to Philadelphia on the same
mission, for in that year an “annual corres-
pondence” was started between the medical
societies of the states of Connecticut, New
York, Pennsylvania and New Jersey. We re-
gret that the subject matter of those corres-
736
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
pondences has not been preserved, for un-
doubtedly it would have thrown considerable
light on the development of medical science,
social and sanitary conditions, and the prog-
ress of preventive medicine in these adjoining
states.
In 1866, for the first time in this country,
use of the alkaloids of cinchona was advo-
cated in the treatment of malaria. In the
same year Dr. Bateman, President of the So-
ciety, reported what was probably the first
attempt at treating disease by intravenous in-
jections. He referred to the report of Dr.
Lorain, evidently in France, as having treated
a case of cholera by intravenous injections of
water, and the patient made a complete re-
covery; probably in spite of the injections.
It is of interest to note in passing that in
this year, 1866, when the Society was 100
years old, there were only 595 practicing
physicians in the state, and 130 cultists, prob-
ably a greater proportion of quacks than at
the present time.
To show again the sanitary and hygienic in-
terests of the State Society, and to indicate
how closely the members at that period were
watching the actions of the legislature, in
1866, Dr. E. M. Hunt, on behalf of a com-
mittee, presented to the legislature the fol-
lowing resolution :
“Resolved , That we hereby express our in-
terest in the attention given to the subject bv
His Excellency, the Governor, in his annual
message to the legislature, and herewith ut-
ter our conviction that there is much need of
such legislation as shall secure in city and
country a more general regard to well-under-
stood sanitary principles and practices.”
The entire state of New Jersey owes a debt
of deep gratitude to our profession, and es-
pecially to Dr. E. M. Hunt, of Metuchen, for
the untiring efforts put forth to have the leg-
islature establish a State Board of Health. In
this effort, Dr. Hunt was ably assisted by Dr.
E. J. Marsh, of Paterson. In a lengthy pa-
per on the subject, read before the Society in
1867, Dr. Hunt said in part : “While ancient
Rome had enlightened provisions for the
health of her citizens in aqueducts, baths,
drainage, methods of sanitary police, which
even yet may excite admiration, and while the
most advanced kingdoms in Europe are now
paying attention to the science of securement
of public health in a way that shows that
those who have control of public health can
no longer fold their hands and shut their eyes
to governmental duty in this direction, it well
behooves American legislation so to inform
itself upon the subject as to enable it to dif-
fuse such information and provide such laws
as shall the better secure the health of the
masses.”
He drew attention to the fact that the
ablest European and American sanatoriums
were demonstrating to the public that croup,
diphtheria, diarrheal diseases, scarlatina, mea-
sles, whooping-cough, erysipelas and puer-
peral fever are dependent upon local avoid-
able influences. In a plea to physicians to
throw themselves into this work for the pro-
tection of the health of the people, apart from
the actual practice of medicine, he related the
following story.
In ancient history, Arnulph, the son of a
physician, was preparing himself for the call-
ing of his father. One day he came to his
father and said: “Father, let me go into a
cloister and serve God.” His father replied:
“Thou doest well to serve God. As a physi-
cian thou mayest serve Him and thy fellow-
men.” That night Arnulph had a vision and,
lo. there appeared an angel with each hand
full of roses. “And why”, said Arnulph, “are
the roses in thy left hand scentless while
those in thy right are full of fragrance?”
And the angel replied : “In my left hand are
the offerings of those who serve the Heavenly
Father without serving his children ; in my
right hand are the offerings of those who
served God and their fellowmen.”
As a result of the long persistent labors of
Drs. Hunt and Marsh, there was created by
the legislature, in i8jj, a State Board of
Health, and Dr. Hunt was its first President.
The state of New Jersey owes an undying
debt of gratitude to those two physicians and
we revere their memory for having been in-
strumental in bringing about what was pos-
sibly the greatest accomplishment of the
Medical Society of New Jersey in the long
vears of its existence.
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
737
In 1872, a law was passed, as one result of
a plea by the profession, making abortion a
criminal act punishable by heavy fine and. im-
prisonment.
In 1878, Dr. H. R, Baldwin, in a presiden-
tial address, first called attention to the prob-
able spread of contagious diseases by milk.
In the same address he advocated the abso-
lute exclusion from schools of all children
from houses where scarlet fever, measles,
diphtheria or whooping-cough were known to
exist. He also advocated, for the first time,
placarding of the premises where contagious
diseases were known to exist. These 2 rec-
ommendations became the very heart of the
sanitary code in reference to the spread of
contagion. Dr. Baldwin’s essay is one of the
most remarkable ever read before our pro-
fession.
In the year 1879, Dr. C. F. Deshler, of
Hightstown, read an essay on “The Medical
Profession and the Public Health”, opening
his address in the following words : “The
lowest conception of the office and work of
the physician is that which includes only him-
self. his patients and his fees. The highest
is that which leads the practitioner to view
the most minute events of his professional
life as directly connected with all medical and
sanitary science and of interest not only for
the profession but to humanity.”
We wish this statement might be found en-
graved on the heart of every physician.
Further on in the address he said : “The
healer is still a God and Hygeia is his child.”
I wonder if he foresaw that “Hygeia”, typi-
fied as the popular publication of the Ameri-
can Medical Association, would be carrying
instruction for mothers into the homes of the
growing generation
In the spring of 1879, a law was passed
establishing the Bureau of Vital Statistics,
and Dr. E. J. Marsh, grandfather of our Dr.
Marsh, of Paterson, who was at that time
the second President of the Board of Health,
did much to establish it on a sound founda-
tion by securing cooperation of the profession
in carrying out its provisions.
In the address of Dr. Deshler, referred to
a moment ago, the doctor went on to say:
“For years the profession had stood as suppli-
cants begging for the simple crust of facts
and figures, hard and dry in themselves but
rich in latent wealth of elements for the cause
of science. We have long importuned the
legislature for this legislation. At last we
have succeeded. (Referring to the establish-
ment of the Bureau of Vital Statistics.) In
our large cities no sooner does an abnormal
death rate appear upon the reports than the
Board of Health decides upon measures for
the immediate arrest and removal of unsani-
tary conditions which cause the destruction of
human health just as an efficient system of
police regulation would arrest suspicious
characters believed to meditate the commis-
sion of crime. Discovery of the transmission
of scarlet fever through milk, typhoid fever,
through drinking water, severe intestinal dis-
eases through impure ice, are important in-
stances of the success of our statistical
methods of observation.”
In 1874, the New Jersey Sanitary Associa-
tion was formed. It consisted of physicians,
health officers, sanitarians, engineers and lay
members. As the years went by this Asso-
ciation served as an interested body between
the profession and the laity and called atten-
tion of the public and the legislature to fur-
ther necessary sanitary reforms.
In 1890, the medical society appointed a
commission of which the late Dr. Henry L.
Coit, of Newark, was chairman, to make an
exhaustive study of the problem of milk sup-
ply and its protection. Dr. Coit had been
deeply interested in the problem for many
years. In 1909, he was instrumental in hav-
ing legislation passed defining and safeguard-
ing “certified milk”. A medical milk com-
mission was formed in New Jersey and now
there are over 100 such in America and many
in Europe. Care in the production, handling
and distribution of milk has been placed on a
basis never even dreamed of before. The su-
pervision of herds, the testing of bovine tu-
berculosis, the medical examination of all em-
ployees, the supervision of dairies, the scien-
tific study of milk ingredients and their
proper proportions, the bacteriologic exam-
inations, the scientific erection and super-
vision of the enormous number of physical
738
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
plants utilized by our national milk supply
firms carrying on one of the nation’s greatest
businesses in food supply, have now become
some of our most potent factors in preventive
medicine. So thoroughly was this work
planned, even to the most minute detail, that
no change has been made in regulations or re-
quirements in 30 years.
While we may be too close to Dr. Coit’s
great life work and history to view it in its
proper perspective or to realize fully what he
accomplished to preserve the lives and health
of the children of the world, we believe that
in time New Jersey will be credited with hav-
ing added another name to the group of im-
mortals to which Jenner, Lister, Koch and
Pasteur belong. The subject matter of this
investigation will be preferred to at length in
our forthcoming History of Medicine in New
Jersey, for ours was the first state in the
Union to adopt a standard for certified milk.
In the same year, Dr. Edgar M. Holden
read a paper before the Society on “The Po-
tential Factors in the Spread of Tuberculosis”.
In 1893, the following resolution was adopt-
ed: “Whereas, the Medical Society of New
Jersey considers it absolutely important that
this disease (bovine tuberculosis) be com-
pletely suppressed because of the danger of
its transmissibility to the human subject; Be
It Resolved : The bill framed and presented
by the committee appointed by the Medical
Society of New Jersey has its full approval
and endorsement ; and Be It Resolved that
the legislature of New Jersey be requested to
pass the bill at its earliest opportunity.”
In 1895, Dr. Alexander Macalister, of
Camden, reported a series of 25 cases of diph-
theria treated with antitoxin, and Dr. God-
frey, of the same city, added 4 more, making
a series of 29 cases so treated with only 2
deaths. In the same year the following reso-
lution was adopted by the State Medical So-
ciety :
“Whereas the welfare of a large class of
unfortunate fellow citizens should, in our
opinion, be paramount to any consideration of
mere economy; therefore,
Be It Resolved, That this society hereby
records its sorrow and regret that the Gov-
ernor of our state withheld his signature from
the bill passed by both Houses of the Legisla-
ture authorizing the formation of a colony
for epileptics ; Resolved further that we will
use our best endeavors to bring about the en-
actment of another bill in the hope that it may
meet a better fate, and thus ameliorate the
condition of a large class of unfortunates.
In 1896, Dr. Elmer, the President, in his
annual address, said in part: “It is the pre-
rogative of the physician as a sanitarian to
lend his influence and education in efforts to
the correction of such evils (unhygienic
methods of living and lack of educational ef-
forts on the part of those well informed to
instruct the ignorant) and we rejoice to know,
and to the credit of our noble profession be it
said that, the world over, the foremost and
valiant leaders in the great battle against pre-
ventive disease, at no matter what sacrifice
of effort or skill and even counting their own
lives in the contest, are physicians. Can you
tell me of any other profession or occupation
where self-interest, self-enrichment, self-
glorification is so universally and unhesitat-
ingly sacrificed to the public weal as is that of
the philanthropic physician? No. In peace
and war, in pestilence wide-spread, or in the
silent chambers of the humble home, his aim
is the preservation of others, the abnegation
of self, the protection of the community and
often his own sustenance is the price paid for
his efforts.”
It will be seen that during this period of
40 years the entire profession in our state
was class conscious in the great matter of
public health. That they were the far-seeing
leaders of thought in this matter and that it
needed constant prodding and repetition of
effort to persuade the legislature to so edu-
cate itself as to follow in their footsteps and
enact the legislation so urgently petitioned.
In 1898 the society recommended to the legis-
lature the enactment of a law which would
effectually prevent defilement of the water
sheds, streams and lakes which were at the
time in use for the collection of potable wa-
ters.
In the same year, legislation was recom-
mended which would establish and maintain
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
739
suitable medical supervision of public schools.
Two years later, such a bill was passed and
jY ezv Jersey had the distinction of being the
first state in the Union to adopt such a mea-
sure. This Act provided that a Board of Edu-
cation might exclude from schools, children
who had not been vaccinated against small-
pox, and some years later another bill was
passed making it compulsory upon parents
who objected to vaccination and had their
children excluded from the schools, to pro-
vide education for them at their own expense.
This bill referred to above also made spe-
cific provisions for the heating, lighting, ven-
tilation and other hygienic conditions in pub-
lic schools.
In 1901, after a long heroic struggle, a bill
was passed by the legislature providing for
the erection of a state sanatorium for the care
and treatment of those suffering with tuber-
culosis.
In his Presidential Address, in 1901, Dr.
Henry J. Mitchell said among other things:
“In New Jersey the foundation for guarding
public health was laid by the Medical Society
of New Jersey when it began the agitation
which resulted in adoption by the legislature
of a permanent system for the collection and
preservation of records of births, marriages
and deaths. In 1866, the legislature appointed
a state sanitary commission composed of Drs.
Coleman, Cooper, Ryerson, Nichols and
Hunt, all members of this society. The re-
port of the commission recommended the en-
actment of a comprehensive Act for the pro-
tection of public health but no further action
was taken by the legislature until 8 years la-
ter, in 1874, when, again in response to re-
quests by this society, an Act was passed
creating a State Health Commission of 6
members, 5 of whom were members of this
society. The report of the inquiries and in-
vestigations made by this commission drew
attention to the preservation of life and the
prevention of sickness which would be effect-
ed in New Jersey by the application of mea-
sures for isolating persons affected by infec-
tious diseases ; for the prevention of the pol-
lution of public water supplies ; for system-
atic removal of waste substances ; for the pre-
vention of sale of unwholesome food ; for the
abatement of nuisances ; and for such other
public service as it should from time to time
be found appropriate to assign by legislative
enactment, to a department of public health;
and in 1877, as a direct consequence of the
recommendations of this society, an Act was
passed establishing state and local Boards of
Health.”
It took more than 23 years to persuade the
legislature to adopt this measure.
It is the writer’s belief, although he has
not had time to make the proper investiga-
tion, that New Jersey was among the very
first states in the Union, if not the first, to
establish, by law, state and local Boards of-
Health. A quotation from an article appear-
ing at this date is as follows : “Until the close
of the eighteenth century, and during several
decades of the nineteenth, almost the only
public health legislation which was enacted
in the American Union consisted in a few
statutes relating to smallpox, since that pes-
tilence was scarcely ever absent from any city
for many years at a time, until after the gen-
eral introduction of vaccination.” Quoting
again from the address of Dr. Mitchell:
“Since the opening of the laboratory (for ex-
amination of tissues and sputum), the exam-
ination of specimens forwarded by physicians
has proceeded without interruption. At the
beginning of this work it was found that an
order of the Postmaster-General prohibited
transmission through the mails of all diseased
tissues, and to New Jersey is due the credit
of successfully demonstrating to the postal
authorities the safety of such transmission
when specimens were properly encased. A
new order was issued by the Post Office au-
thorities, permitting the use of the mails for
this purpose.”
The discovery by Koch of the tuberculosis
bacillus in 1882, gave the world a working
knowledge of tuberculosis and consequently
there were rapid developments in its control
and prevention. Sanatoriums sprang up, first
in Switzerland, then all over the world. Our
own Dr. Edward Trudeau, while engaged in
practice in the city of New York, developed
pulmonary tuberculosis and decided to try the
740
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
sanatorium treatment on himself, in the Adi-
rondacks. Regaining his health to a large de-
gree, he started a small sanatorium for others,
at Saranac. This was in 1884, and it was the
starting point for the rest and sanatorium
treatment in America. In a few years Sar-
anac was known all over the world.
It was* not until 1907 that our New Jersey
State Sanatorium was erected at Glen Gard-
ner. For a number of years the medical pro-
fession had been interesting lay groups all
over the country in the formation of tuber-
culosis associations, resulting in the formation
of the National Tuberculosis Association in
1904. In 1906 the New Jersey Association
for the Relief and Prevention of Tuberculosis
was organized. A thorough, systematic plan
was adopted, providing sanatorium treatment
for the incipient, hospital care for the ad-
vanced, dispensaries where individual cases
could be examined and patients advised how
to live, visiting nurses to see that the advice
given was carried out at home, medical in-
spection of the school children, education of
the public through exhibits, lectures and dis-
tribution of literature, and enforcement of the
anti-spitting ordinance. By 1908, 21 local
committees had been formed in different sec-
tions of the state. In that year the State
Board of Health adopted a set of aphorisms
on how to keep well and avoid tuberculosis.
These were placed on charts and issued with
a circular on “How to Drill Children”, and
were sent to 11,000 schools in the state.
In 1910, a bill was introduced in the legis-
lature to permit counties to erect hospitals
for the treatment of incipient and advanced
cases, and 2 years later the bill was passed and
became a law. I mention this lapse of only
2 years to indicate that in these later years,
due to the education and diffusion of ideas by
the medical profession in regard to commun-
icable diseases, it was much easier than there-
tofore to secure cooperation of the legisla-
ture.
In 1911, a law was passed abolishing drink-
ing cups in schools and public places and an
appropriation of $10,000,000 was given by the
legislature to the State Board of Health to
combat tuberculosis. In 1912, a statutory pro-
vision was enacted for the compulsory re-
moval to hospitals of careless and indigent
patients. This is a brief report of the ac-
complishments to date. Much yet remains to
be done and there is a crying need for state
preventoriums for children. This coopera-
tive work has cut the death rate of tuberculo-
sis by probably 50% and a large number of
cases has been uncovered which never would
have been found or treated except for this
state-wide supervision. I am indebted to Mr.
Easton, Secretary of the New Jersey Tuber-
culosis League, for the data submitted above.
The first President of the New Jersey As-
sociation for the Prevention and Control of
Tuberculosis, and the first President of the
Board of Managers of the Hudson County
Tuberculosis Sanatorium, was our revered
Fellow, Dr. Gordon K. Dickinson, who has
joined the galaxy of our illustrious fore-
fathers in medicine in the Great Beyond. New
Jersey should place his name at the top of
the honor list of those in our profession who,
through the past half century, have labored
for the welfare of humanity in this state.
It will be my pleasure to introduce a resol-
ution at the Annual Meeting of the Medical
Society of New Jersey this year providing
that this body place a suitable tablet on the
walls of the Glen Gardner Sanatorium com-
memorating the work of Dr. Dickinson in the
prevention and control of tuberculosis.
This report on tuberculosis has carried us
a little afield of our chronologic arrangement.
To resume this, in the year 1900, a law was
passed providing for the medical examination
of public school children and again New Jer-
sey was the first state in the Union to adopt
such a measure.
In 1903, an Act was passed by the legisla-
ture prohibiting spitting on the floors of pas-
senger cars.
In 1908, at the instigation of the Medical
Society of New Jersey, the legislature ap-
pointed a commission and made an appropria-
tion for the extermination of mosquitoes, and,
compared with the vast number of these dis-
ease spreading pests formerly present in the
state, we are now comparatively free from,
the spread of disease by this method.
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
741
In 1910, the activities of the Medical So-
ciety of New Jersey drew the following re-
marks of appreciation from Governor George
S. Silzer: “Your society is doing splendid
work in New Jersey in raising standards
which must necessarily eventually result in
public good. There is much important work
to be done in public health matters in New
Jersey, in which the advice and cooperation
of the physicians are important and essential,
and I trust that your body will continue its
good work along these lines.”
In 1914, a committee of the State Medical
Society was delegated to standardize the hos-
pitals in the state. Again this work was done
in New Jersey before it was adopted else-
where. Indeed, the Alnerican Medical Asso-
ciation and the American College of Sur-
geons took a leaf and a brief from the work
of our medical society in adopting this plan
at a later date.
In 1916 a law was enacted for the control
of ophthalmia neonatorium and the Bureau of
Vital Statistics made it compulsory to desig-
nate on birth reports just what preventive
measure was employed in each individual
case.
In 1917, a law was passed making the re-
port of venereal diseases compulsory. In the
same year an enactment provided for the an-
nual registration of midwives.
In 1924, the state society went on record
favoring periodic health examinations. In the
same year the Medical Society of New Jersey
made a radical advance in preventive medi-
cine. Without any appropriation from the
state and at an annual expense of $10,000 a
year, the society, through the efforts of Dr.
Wells P. Eagleton, secured the services of an
Executive Secretary to carry to the public,
through various clubs, associations and wel-
fare groups, medical education in matters per-
taining to health.
From its very inception the plan met with
unqualified success. After a trial of 2 years,
the demand upon the time of the Executive
Secretary became so great it was necessary
to secure the services of a Field Secretary to
carry on this work. At the time of this writ-
ing, these health talks have become so pop-
ular that over 60.000 people are listening to
the lectures and it is almost impossible for the
Field Secretary to meet the demands upon her
time.
In the same year Dr. Henry O. Reik and
the writer conceived what they thought at the
time was an original idea in creating the Tri-
state Conference, wherein the Officers and
Editors of the State Medical Societies in New
York, Pennsylvania and New Jersey would
meet 3 times a year to confer on all medical
matters of interest to the profession in these
3 adjacent states. Representing as we do,
25% of the population of the nation, and 24%
of the physicians in the country, the oppor-
tunity for accomplishing far-reaching results
is indeed great. And even the work of this
important conference has largely turned to
public health matters.
In 1927, a law was passed providing for the
protection of the health of labor in factories.
It made mandatory fire escapes, guards on
machines, dust removing devices and the con-
trol of noxious and deadly gases and fumes.
Dr. Andrew F. McBride, the Commissioner
of Labor at that time, was largely responsible
for this enactment. He also established Re-
habilitation Clinics over the state where in-
jured employees could be treated and brought
back into productive activity so as to lessen
the burden on the state.
In 1928, an attempt was made by the so-
ciety to have enacted legislation for the con-
trol of rabies. In this, however, we were un-
successful.
In the same year, the society gave its hearty
support to plans and arrangements for a com-
mission appointed by the Governor of the
state to make a survey of our crippled chil-
dren, and this year we have gone on record
favoring the permanent appointment of this
commission with the provision that a physi-
cian, chosen by the State Medical Society, be
made one of its members. Formerly we had
fought for years to have medical men ap-
pointed on these important state bodies and
commissions, without success, but this year
the necessity for medical representation on
this particular commission was readily appre-
ciated.
742
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
In 1928, a law was passed, largely through
the efforts of Dr. Henry B. Orton, of New-
ark, providing for poison labels on all prep-
arations of lye placed on the market.
In 1929 and 1930, the Medical Society of
New Jersey put into effect a plan to immun-
ize all school children in • the state against
diphtheria by the administration of toxin-anti-
toxin. At the close of 2 years’ aggressive
action, in conjunction with the state and local
Boards of Health, and with the active assist-
ance and cooperation of the Prudential Life
Insurance Company, and the Metropolitan
Life Insurance Company of New York, and
the financial assistance of some public spirited
friends, we believe that about 500,000 chil-
dren have been so protected. We are now at-
tempting to have all preschool children given
similar protection. If we could only secure
cooperation of the parents, diphtheria would
be wiped out of the state.
In this survey of what the Medical Society
of New Jersey has accomplished in the last
165 years, in the advancement of preventive
medicine, and to bring the subject matter
within the confines of a single paper, it has
been necessary to hurry OA'er the field. A
whole volume could easily be written on the
subject.
At the present time when platform speak-
ers, soap-box orators, the press and many of
the influential first-class periodicals in the
country are freely criticising the medical pro-
fession, it has been with profound satisfaction
that the material for this paper has been col-
laborated. We have demonstrated conclu-
sively the high place the Medical Society of
New Jersey, and the entire profession in the
state, has always held in constructive advance-
ment of public health.
We have indicated how we have led and
how the legislature has been painfully slow
to follow, how we have been compelled to
wring from that body consent to put into le-
gal enactment the measures we have so earn-
estly advocated for years.
Massachusetts was the first state in the
Union to adopt a proper law for the disposal
of sewage. New Jersey was the second state
to do so. We were among the first to estab-
lish a State Board of Health. We were the
first state to adopt measures for the medical
examination of school children. We were the
first to adopt a standard for certified milk, the
first to secure from the federal authorities
permission to send tissues and specimens
through the mail to central laboratories for
examination, the first state to standardize its
hospitals, the first state to place all private
hospitals under state control, the first to pro-
vide for mosquito extermination, and among
the first to enact a law for the prevention of
ophthalmia neonatorium.
This is indeed an enviable record of which
we may be justly proud.
I cannot close this article without giving
credit to the State Board of Health, to the
Board of Llealth of the City of Newark, and
particularly to Dr. Julius Levy for their ex-
cellent work in preventive medicine. This
field as outlined bv them covers :
Prenatal care of expectant mothers, su-
pervision for one year of babies delivered by
midwives and in wards of hospitals, Little
Mother’s League at each school, consultant
stations with 18 conferences each week in
schools, supervision of midwives, supervision
of day nurseries, wet nurses’ directory, pre-
vention and supervision of ophthalmia neo-
natorum, detection and cure of syphilis
among supervised babies, housing, sanitation,
poverty, unmarried mother’s problem, super-
vision of children to school age, convalescent
homes for mothers, obstetric out-patient de-
partment, municipal school of midwifery and
establishment of children’s dispensaries in
congested areas.
Since the introduction of the above mea-
sures, the infant mortality in the City of
Newark has fallen by leaps and bounds, and
last year the City of Newark was credited
with having the lowest infant mortality of any
city of its size in America.
We believe that in the future, as in the
past, our profession, acting through the ef-
forts of the Medical Society of New Jersey,
and in its contact with the public, will con-
tinue to follow in the foot-steps of our illus-
trious predecessors, demonstrating to the
world at large that our first and foremost
duty and pleasure is the service of mankind.
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
743
THE PRACTITIONER’S VIEW OF
MEDICAL ECONOMICS
F. I. Krauss, M.D.,
Chatham, N. J.
Practically every young man who enters the
profession of medicine does so primarily be-
cause of an urge to help his fellow man. Very
rarely does any one consider this profession
as a means to amass a fortune or to acquire
social prestige. The road is too long and te-
dious for the fortune hunter. I have yet to
meet the man who has taken up medicine ex-
cept for love of the work. He takes it for
granted that he will make an ordinary living
in the course of time, but nothing more.
After a short period in practice, certain
hard economic facts, from which there is no
escape, are forced upon him, and he comes
to the rude awakening that money governs
his practice almost as much as it does every
other business or profession. When he be-
gins to realize this, and couples it with the
disappointment he normally feels when his
patients cannot be cured of many of their
desperate illnesses, and then get well of their
minor illnesses without assistance, he is like-
ly to become pessimistic or cynical about his
life’s work. Furthermore, he is reading at
present all kinds of attacks, in all types of
magazines, on the charges of doctors and the
cost of illness. Everybody seems to be try-
ing to accuse the medical profession in terms,
veiled, polite, or otherwise, of being highway
robbers. One would think we are taking bread
from the hungry, and that we are akin to the
barons and bishops of medieval times. Medi-
cal costs are being investigated by amateur
sociologists from the automobile manufac-
turer to the chain store groceryman. No
automobile manufacturer suggests that peo-
ple buy fewer or cheaper automobiles, and no
chain store owner suggests that poor people
eat fewer luxurious foods, wear plainer cloth-
ing, and live on the humbler fare of their
forefathers. These are all in the line of civ-
ilization and progress, and are legitimate ex-
penses. They argue that x-rays, blood chem-
istry, immunization against disease, are also
in the line of progress, but that they should
be given away or else paid for by some pan-
acea of a system whereby everybody pays for
the other fellow; distribute the cost by tax-
ation, by jDublic foundations, by public clinics,
by any method you wish so long as the indi-
vidual is hood-winked with thinking he is not
paying for it.
All these lay articles assume certain prem-
ises.
First, that medical charges are too high for
the average worker. This is not a new slo-
gan. All of us, who have been in practice
any length of time, know that this has been
said from the beginning. One man cannot
pay because he has too many children, another
because he is out of work a few months. He
may have an automobile or a radio on the
installment plan ; that is a legitimate expense.
Watch the construction of any building and
see the laborers arriving in much better auto-
mobiles than the average doctor drives. Go
into their homes and see better radios than we
possess. See fruits from all over the coun-
try on their tables. Who wears cotton stock-
ings and underwear? These are hard facts.
Yet, they mean nothing to the economist who
would socialize a legitimate profession. They
do not give free groceries, or free coal, or
even a discount to those who say they cannot
afford to pay, and yet those commodities are
just as important to sustain life as is medical
care. If one asks for charity in any other
line except medicine, the whole social ma-
chinery is set to work to find out if it is a
worthy case ; if so, then only the minimum
amount of help is given. But the doctor or
the hospital must ask no questions, refuse no
help at any time, for fear of hurting some-
body’s feelings or of being accused of being
hard-hearted. Everything must be done as
if the patient were conferring a favor. Any
physician can give innumerable illustrations
of this condition.
Another argument advanced is, that doc-
tors should reduce charges by cooperation and
combination in group partnerships and clin-
ics ; that specialists should so combine that
■ their knowledge is available at a lower fee.
At the head of such a group should be some
one who will summarize a patient’s condition
744
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
and decide which of these specialists the pa-
tient should see. Not one of these men will
know or study the patient as an individual.
Any one of you who has talked with patients
who have been through such a mill, knows the
mental confusion, frequently depression, and
discouragement which results. Pity the poor
patient who has a soul as well as a body. We
are not running an assembly plant or a parts
factory.
The individual does care who takes care of
him or his family. The higher the mental
and emotional development, the more intense
is this attitude. Faith in the ability and in-
tegrity of his physician is the keystone on
which he builds. When you have been away
on vacations, and on return have had patient
after patient report that he waited for you
rather than go to a stranger, you realize the
importance of this bond. T his is the com-
pensation to you for the fickleness and lack
of Joyalty of many others. When anxious
relatives and well meaning friends suggest to
the patient — why don’t you try this doctor or
this quack who has done such marvelous
things for someone else? — and the patient
still stays loyal, the very last thing the doc-
tor thinks about is the financial return from
that patient.
Public health programs seriously cut the
■doctor’s income. There are public health
nurses, insurance nurses, Red Cross nurses,
school nurses, and so on. All these nurses
are doing some prescribing of diets and treat-
ments, and are treating minor injuries and
sicknesses which would normally be brought
to doctors’ offices. We have no quarrel with
proper, legitimate nursing but we are begin-
ning to appreciate the economic injury which
is being done, particularly to the younger
practitioners.
Every community has its diphtheria pre-
vention program. Children are immunized by
public health organizations without any ques-
tion as to the financial status of the family.
This is a purely individual health measure
paid for by taxation. Now, after people have
become accustomed to this system, state
boards of health are making a half-hearted
endeavor to persuade people to go to the fam-
ily physician for earl}' immunization. Pa-
tients ask why they should pay when the
school or board of health will do it free. If
immunization is part of a public health pro-
gram, make the matter compulsory and carry
it through to its logical conclusion. Do the
same with smallpox vaccination, with scaidet
fever, with typhoid. A public health measure
paid for by taxation should leave no freedom
of choice to the individual. If my taxes are
paying for immunization, I have a right to
demand that everybody’s child, and, for that
matter, every non-immune person, be immun-
ized. ■ There is no other way in which the
state can logically serve the community. The
public health program should protect the in-
dividual only so far as he is part of the whole,
and in respect to his status as a menace to
others.
In line with snch public health programs,
large industrial corporations are taking care
of their employees and even their families in
a paternalistic manner. Wage earners, whose
salaries are adequate for all necessary com-
forts and some luxuries, are given the impres-
sion that medical care costs nothing. Conse-
quently, when they do have to pay a physician
or surgeon what his work is worth they feel
they are being imposed upon. They have
not been taught to respect either the physi-
cian or his knowledge.
There is also a tremendous abuse of the
free clinic. Practically no investigation is
made of the social status of clinic patients.
For a mere pittance, many dollars worth of
service is given away. Young doctors are ex-
ploited to give their services under the de-
lusion that they are being honored by having
a position on the staff. So wonderfully or-
ganized is this system that crowds of men
wait for the opportunity. Fortunately, doc-
tors are gradually realizing this injustice, and
a movement is under way in some of the
larger institutions to pay the doctor some-
thing. Let us oppose vigorously the estab-
lishment of unnecessary clinics, particularly
in our suburban hospitals. Let us demand that
clinic cases be true clinic cases from the eco-
nomic view, and that the recipient of public
charity prove his need.
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
745
They tell us to consider the wonderful
care that patients receive in the wards and
clinics of hospitals; that the poor receive bet-
ter treatment there than most receive at home.
Undoubtedly, they receive the best scientific
care that we are able to give ; they are ana-
lyzed and studied and treated as pathologic
conditions. The attending physician directs,
the resident intern over-sees, and the nurses
carry out the orders. This is all done in a
cheerful, efficient manner, but the patient as
an individual means little, and the doctor
would pass him the next week on the street
without knowing him. In my work as a pe-
diatrician, I encounter the greatest resistance
in getting parents to consent to hospital medi-
cal care for infants and young children. They
appreciate that for surgery there is no other
solution, but for medicine they will do al-
most anything to keep the child at home.
Many are the charity patients that I have tak-
en care of in my office, when I am not on ser-
vice, because children have been brought to
me for my individual care. I cannot persuade
those parents that someone else on the service
will take just as good care of the child. The
emotions are more powerful than the intellect,
especially with those whose training has been
elemental.
Moreover, the greater the economic inde-
pendence, the more patients will insist on this
freedom of choice. Naturally, if one can
afford to pay for individual service, one is
going to obtain it if possible. Why deny this
right to the worker, if he wishes it, any more
than the financier?
In a consideration of the amount of pure
charity work that a physician should do, we
cannot judge the present by the past. When
communities were stabilized, when the pop-
ulation was not in a constant state of flux, the
physician knew who was worthy of charity
and who was not. Today we can only guess
at individual wealth. The easy-going physi-
cian can be unmercifully imposed upon. For-
tunately, most people are self-respecting and
honest and do not need investigation they
wish to pay fair fees for individual service.
We do not need to ask for references when
they open an account. 1 he experienced
physician can quickly recognize a “dead beat”.
Our worthy charity work is actually a plea-
sure because it entirely satisfies the original
desire we had to help people. However, we
can go on the general assumption that in this
country charity to unknown persons is not
necessary, and that at least some fee is in or-
der. I have found that those who expect
charity without question, as if it were their
right, are usually most ungrateful and are
social parasites.
The controversy as to what is a charity
case frequently causes ill feeling between doc-
tors and social workers. The social worker
is paid for her services and actually gives
nothing ; she literally is not doing charity
work herself although given credit for it by
the people. Her judgment is very likely to
be biased in favor of the applicant, partly be-
cause it is a normal sentimental feeling and
partly because her records of the amount of
work she has done will determine her value
to the organization employing her. When a
physician is employed by a similar organiza-
tion, or by the city, he also is paid for his
services and cannot be considered as doing
charity work. Most of the free work in a
community should be cared for in this way.
When the hospital is asked for free services
for a patient it should be entitled to a full
history of the situation so that it can decide
for itself whether or not the case is worthy.
It should not be expected to take the word of
a social worker not under its employ. The
hospital is responsible to its staff not to do
promiscuous charity work. A patient having
been accepted by the hospital should not be
questioned by the physician. If, as happens
occasionally, he is imposed upon, the hospital
authorities and not he should make the in-
vestigation.
We doctors sometimes make the mistake of
assuming the principle of pay a full fee or pay
nothing. This is embarrassing to the honest
poor who are thereby encouraged to go to
clinics where they feel they can maintain their
self-respect. It is not beneath our dignity to
tell a patient what our regular charge is, but
that if he cannot afford to pay it we are per-
fectly willing to adjust it according to the
746
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
circumstances. This is real social service, and
the respect of both parties can be upheld. I
do this regularly where my instinct tells me
it is necessary, and I am very seldom im-
posed upon.
The cost of services to the consumer is
governed by economic laws ; production and
distribution costs apply to everything. They
also apply to medicine. There is no medical
monopoly. Individual competition obtains as
in any business.
The cost of a medical education, as in any
profession requiring specialized knowledge
beyond high-school training, is borne first of
all by the parent of the student. He must in-
vest thousands of dollars in a most hazardous
investment. We may say he is doing it for
love of his child; nevertheless it is an invest-
ment from which he expects that child to re-
ceive a commensurate return.
The student invests his freedom up to the
age of between 26 and 30 years. During that
time he is not free to do what other normal
young men are doing. He has no financial in-
dependence, he must ask for everything he
has, he may not enjoy free evenings, he may
not marry, he may not seek a change of oc-
cupation without losing everything previously
invested. When he graduates from his hos-
pital he has absolutely no capital investment
and no income. This at a time of life when
most men of his age have homes, family, and
secured positions. What return can he ex-
pect for this?
First, he has the personal satisfaction of
belonging to one of the oldest and most hon-
orable professions in existence, the annals of
which are filled with sacrifice and heroism far
beyond that of any other profession. This
will give him courage to withstand many a
temptation, and to hold his own against dis-
couragements and fears which few even
dream of. It is his personal religion.
Secondly, he has the opportunity to know
and study human nature from its heights to
its depths. This gives a wide tolerance, and
a sympathy which makes all men brothers.
He hates sham and loathes hypocrisy. He is
not afraid of death. He develops a faith
which makes him secure beyond church and
creed.
Thirdly, he has the satisfaction of looking
forward to a useful life so that when he
leaves the world it may have been better for
his having lived. This is his immortality.
You may argue that he will have all this
under socialized medicine. He will not !
Everything hinges on intimate personal con-
tact between him and the patients who trust
him voluntarily, and who do not come to him
merely as to a vender of knowledge. Without
such patients, his whole career is a failure.
But none of these things, however person-
ally glorious, will pay his rent, clothe and
educate his children and give him material re-
turns to which, economically speaking, he is
entitled.
What monentarv return for this service as a
general practitioner must he require? We
will take it for granted that his income should
be adequate for a normal life for himself and
family. For the present we will not consider
the charges of the expert or specialist. We
cannot judge the necessary income of any pro-
fessional man, lawyer or engineer, by the
charges of the few highly paid consultants.
I am writing of the rank and file. There are
certain fixed overhead expenses which cannot
be avoided. An office is the first essential.
There seems to be a popular idea that be-
cause many doctors have taken part of their
homes as offices, there is no expense attached.
If the doctor has his home and office com-
bined, he must of necessity, in order to be ac-
cessible, live in a section of his town or city
which is devoted to business. He either pays
more for his property or pays higher rent.
This means also that he cannot live in an en-
vironment congenial to himself and family.
They are to that extent socially isolated. This
affects his children in the choice of their as-
sociates. If he does not have his office in his
home, and I believe that no doctor should be
compelled by finances to do so, he has the
same overhead to consider as any other busi-
ness or profession. He must pay additional
office rent.
Included in the office, no matter where sit-
uated, is the cost of equipment, which, if com-
plete, mounts into the thousands of dollars.
The time is long past when a medicine satchel
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
747
and a stethoscope are sufficient. They have
gone the way of the oil lamp.
He needs an office nurse or secretary.
Someone must be present for his examina-
tions, or he is in danger of being black-mailed
by some hysterical or malicious woman.
Someone must answer his telephone all day ;
this is not the family job, and if he has even-
ing office hours he must pay extra for over-
time employment. The curse of the home of-
fice is the evening office hour and the Sunday
office hour. I have always maintained that
these are seldom necessary, except for emer-
gencies. There is no more reason why pa-
tients cannot come to the doctor during the
day, than that they cannot go to the dentist,
to the lawyer, or to the merchant. If these
men kept their offices or stores open in the
evenings and Sundays, people would seek
them at those times also. If doctors as a
whole would discontinue this practice, they
would be more respected and would have hap-
pier families. Patients would make it their
business to come at the proper time. A phy-
sician has just as much right to charge extra
for evening work as any laborer. What other
profession works from 8 a. m. to 9 or 10
p. m.? Patients say they cannot come at other
times — but what they mean is that it is not
convenient for them. Conveniences of this
type should be paid for.
Then there is the automobile — a necessary
expense and a heavy one. His business car
should not lie confused with the family car.
His family is entitled to its individual car as
much as is any other family, and the 2 ma-
chines should be reckoned entirely separate.
Other necessary expenses are vacations,
when income ceases completely — time off is
a total loss. Salaried executives and clerks
receive vacations with pay — not so the doc-
tor. Merchants have clerks — few patients
want the doctor’s assistant, if he has one. The
same rule applies to his own periods of ill-
ness.
As he grows older and his knowledge and
skill increase, he is physically unable to do so
much work, but, let him refuse a silly night
call on the basis of decreased physical en-
durance, and he is likely to lose a family.
Patients say they don’t want a doctor who
does not make night calls. This hurts his
practice among new people.
All this time he is not building up a saleable
estate or business. He can never retire and
still maintain a financial interest. His prac-
tice cannot be sold; it is worth nothing to
any one else when he dies. His investment
is gone into thin air. Try to sell a profes-
sional man’s equipment, and see what it is
worth.
A very serious obstacle to low medical fees
is the competition by the horde of quacks al-
lowed to practice their cults. Every physi-
cian’s income has been hurt severely by the
amount of work they have taken. No one
objects to honest competition; it is a healthy
economic law. The objection is based on the
inadequate training, the blatant pretenses and
the charlatanism with which cultists claim the
right to treat humanity, and the audacity with
which they seek to undermine the progress
of science. One could even pardon this on
the plea of ignorance if they did not seek to
abandon their cults, and enter medicine and
surgery by the back door, while still retain-
ing their clients who have come to them in
blind faith. A loss in volume of work done
must be compensated for by a rise in cost if
the work is to continue. As long as the leg-
islatures fail to protect those to whom they
have given the responsibility of public health,
this result must obtain.
These are some of the reasons why medical
costs, as applied particularly to physicians,
cannot be reduced. The question follows —
what should the individual physician charge
over and above the actual cost of practice —
in other words, what should his profits be?
His charges are fixed to a certain extent by
the community in which he lives. Where
money is plentiful, and worth less to the in-
dividual, all costs are higher proportionately
than in a community composed of laborers or
clerks, where the dollar has a higher value.
Therefore, the same services will command
different returns in one section than in an-
other. Most physicians have a mixed clien-
tele. If he charged his minimum cost rates
to all, he could not do enough work in a day
748
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
to make a living commensurate to the value of
the services he gives. The wealthier the in-
dividual the more detailed attention he de-
mands and the charge must be in proportion.
One cannot treat this class with a quick busi-
ness-like precision. For the time alone con-
sumed, one visit may be worth 3 or 4 times
as much as another. Therefore, I do not be-
lieve that physicians should be classified as
charging so much for an office or house visit.
When people ask me my fee, I always reply
“it will be in proportion to the services ren-
dered’. I have a minimum charge adjusted
on a cost basis. These charges are not fixed
from year to year any more than the price of
any commodity is stabilized.
I believe that telephone consultations should
be charged for. I go on the basis of Yi the
office fee, having found that many were abus-
ing the privilege of asking for advice over
the telephone, when without telephone facil-
ities they would have come to the office. This
does not mean that every simple question ask-
ed by telephone is to be classified as a con-
sultation. The physician should reserve the
right to make his own decision. If you will
keep a record, you will be amazed at the
amount of free advice you give this way,
whereas it should be a legitimate part of your
income.
Night calls should be charged for properly.
Broken rest interferes with one’s efficiency the
next day. A night call means at least 1 hour,
besides the fact that one can rarely sleep
soundly again for the rest of the night. Dou-
ble the day fee is by no means sufficient to
compensate for this. Proper charges for
night calls will eliminate at least 75% of them.
The family will call the next morning and
say : “Doctor, I wanted to call you last night
but hated to disturb you.” You know what
they really mean is that they considered the
cost and decided to wait until morning.
Charge also for experience. The man who
has been in practice 20 years knows propor-
tionately more than the recent graduate. If
he has kept abreast with medical progress
his judgment is worth a great deal. The
experienced engineer or lawyer expects to be
paid for his knowledge, the young engineer
or lawyer obtains less. The same standard
should obtain in medicine. Patients would
then more frequently consult the physician
expecting to pay for his knowledge. Plow
many times do you hear the remark : “I want
the best doctor or surgeon I can get.” A great
deal of our work is routine, and can be done
by the average man.
Some patients seem to take a certain ego-
tistic pride in telling whom they have con-
sulted, a certain professor or specialist, and
they come to you as a suburban doctor as if
they were doing you a favor. They want
what they call “a complete examination”.
This is to be done in 1 visit and an ordinary
office fee charged. Do not be bluffed by this
type. Tell them frankly before you begin
what such an examination means and what
it will cost ; let them know that your knowl-
edge is worth something also, and just because
you don’t happen to care to live in a big city
does not mean that you know less medicine.
There is another type of family which ex-
pects to have two or more members taken care
of for the same cost as one. The doctor is in
the house, therefore, ask him questions about
as many as possible. I remember particularly
during the influenza epidemic in 1918, when
we were taking care of whole families, that
there were many complaints because each in-
dividual was charged for. Except in case of
poverty this should be done. There is ab-
solutely no reason why it should not be so.
Fees in proportion to the responsibility of
a case are also reasonable. The law takes
cognizance of the relative value of a life ; i.e.,
the workman’s life is not as valuable as the
capitalist’s. The same has obtained in medi-
cine from time immemorial. You may treat
one case of pneumonia at so much, and an-
other at an entirely different fee. You do
the same in surgery and obstetrics. The
question was asked me — “How can a doctor
determine what is fair?” — and I replied: “By
the family’s scale of living and social status.”
My friend thought that fees should be fixed
as railroad fares are fixed; and that the same
law should obtain in medicine — either do
without if you can’t afford it or obtain cheap-
er services. He did not think it fair that the
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
749
individual doctor should have a sliding scale
of charges. I said: “We are operating on
your daughter and the operating fee will be
so much ; now, shall I refuse to operate on
your gardener’s child because he cannot pay
that amount?” He could not but feel that he
was being over-charged for the sake of the
poorer man, and that it was not up to me to
compel him to help make up the difference.
There is some justice in this view; it is hard
for a business man to think otherwise. In an
endeavor to stabilize fees for people who
think this way, some hospital staffs have
agreed on certain charges for specified opera-
tions irrespective ot the financial status of the
individual. If the doctor could be sure of
being paid for the full value of his services,
as in any business transaction, I think this
arrangement, if it were possible, would be
satisfactory to a great many of us. None of
us are satisfied with the constant financial un-
certainty about what to charge.
The proportion between the income of the
specialist and the general practitioner is a
cause of unrest. Specialism has been over-
done; it has become a habit for the public to
seek the specialist before the family physi-
cian. There are several reasons for this which
ought to be corrected.
First, the general practitioner has forgot-
ten that he ought to take care of at least 95%
of all his patients. He has been too ready to
throw the responsibility for difficult cases on
some one else’s shoulders. This has naturally
given the public the impression that the family
doctor does not know very much. The spe-
cialist himself has not helped any by often be-
ing remiss in giving the practitioner his due.
Second, there has been no control of spe-
cialization in this country. Medical students
have become enamoured with the ease with
which they may seemingly obtain this stand-
ard. A few months or a year of study after a
general internship and they start out in some
specialty, with practically no knowledge of
the relationship of disease as a whole, with no
actual experience in the continuity of path-
ologic conditions, without judgment based on
years of observation. The meekness with
which men with years of clinical experience
have stood for this is amazing.
The mere fact that one chooses to limit the
kind of work he is doing does not in my judg-
ment entitle him to fees out of proportion to
the value of the services rendered. Skill and
knowledge of a high-class, technical type is
another matter entirely. Let the general
practitioner charge properly for the work he
can do, and let him not hesitate to come out
with the truth.
The same thing obtains in surgery. Most
well trained physicians today can do ordi-
nary surgery. They have as much right to do
this as most of the men who call themselves
surgeons, and who are still doing medical
practice. Go through the country districts,
see the general practitioner operating in some
farm-house with perhaps one assistant, watch
him deliver a forceps case on a sagging bed,
observe him repair a broken leg or sew up
severed tendons with as good results as are
obtained in many an up-to-date hospital. Put
that same doctor in a hospital, and he im-
mediately gets an inferiority complex. There,
he is not qualified to do anything because his
technic is not just so, and because there are
a lot of white-gowned assistants standing
around waiting for an opportunity to laugh
at him. I have no patience with all the red
tape put in the way of such a man, questions
raised whether he should be allowed to do sur-
gery on his own private patients ; and then no
questions asked when the surgeon in that hos-
pital takes cases of pneumonia, typhoid, in-
fant feeding and what not. It is a “holier
than thou” attitude which physicians have a
right to resent. No conscientious man will
undertake any case which he feels he cannot
handle. The responsibility is his.
As you have observed, this is a paper in
defense of the general practitioner, a protest
raised against his submersion into oblivion.
I believe it is tremendously important to the
public welfare whether or not he survives as
an individual. I personally believe he will.
So far, I have considered the doctor as an
individualist. There is the other aspect of
his profession which is causing much concern.
The prevention of illness and disability, the
care of the indigent, are some of the divisions
of the social duties of organized medicine.
There is a growing demand that these prob-
750
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
kills receive attention from the state and na-
tional government. A resistance by the medi-
cal man to this legitimate movement will be
to his detriment. We must cooperate with
those who have this at heart. Do not judge
from the preceding statements that I am op-
posed to welfare and philanthropic work. I
think it most unfortunate and unwise that so
many of these projects are undertaken by en-
thusiasts without the cooperation and direc-
tion of competent medical advisers. We must
share much of the blame for this as we have
stood aloof too long. There was a time when
the public s knowledge of medical affairs was
at least 10 years behind; if we are not care-
ful we may soon find that we will be the ones
in the rear of progress in social medicine.
The ethics of the profession will not be harm-
ed by a broader view of our social duties.
The industrial physician, the city physician,
the welfare physician, is entitled to as much
respect as the individual practitioner. If his
work is properly defined it will be of tremen-
dous value not only to the public but to the
profession as well. He will relieve the doc-
tor of all legitimate charity work, and thus
make more feasible a true economic status
for charges. I believe the general self-sup-
porting population can be educated to the
proper expenses allowable for illness, and the
need of preparing for these expenses, if we
would lead public opinion in its medical edu-
cation. The more we do this, and do not
side-step the issue for welfare workers to
handle, the less will be the danger of ill-con-
sidered state medicine. If some form of
health insurance is the solution, the medical
profession will be prepared for the leader-
ship.
I am not attempting to give a solution for
the economic ills of the community. Eco-
nomic laws are the same as ever. Supply and
demand govern price. The teaching of thrift
and living within one's means are the key-
notes of credit. Legitimate insurance for
sickness is just as feasible as insurance for
accident, for life, for fire and other hazards,
i he savings bank is available for all. If some
families will have things beyond their social
position, they cannot expect the medical pro-
fession to hold the bag. It is not up to us to
finance them, to give them free medical care,
nor is it for the state to do so. The state
has no more right to do this than to give free
food, clothing, and fuel. If the state, through
a mistaken idea of democracy or socialism,
should attempt it, those who will sufifer ulti-
mately will be the recipient. The medical pro-
fession will suffer temporarily, and many of
us individually, but the experiment if tried
will eventually prove that medicine as an in-
dividual service to humanity will be indis-
pensable so long as suffering endures.
MOSES MAIMONIDES— PHYSICIAN
AND PHILOSOPHER*
S. SCHIFFMANN, M.D.,
Newark, New Jersey
Moses Maimonides was born on March 30
(Nisan 14), 1135, at Cordova, Spain. His
genealogy has been traced to Judah, the
Prince, the compiler of the Mishnah, and
through him to the royal house of David.
Of the boyhood of Moses we know little.
Legend has been busy with him and story
goes that the child revealed but little of the
man. But the contrast thus drawn between
the dull; idle lad and the brilliant, industrious
man, is unfounded. The father, Maimon,
whose first name was Baruch, was a scholar
and a man of enlightenment; Talmudist, as-
tronomer and mathematician. Maimon was
a disciple of Joseph ibn Migash (1077-1141)
who had imbibed the spirit of Alfassi and
who had succeeded the latter as the head of
the school at Lucena. The poet, Jehuda
Halevi, eulogized ibn Migash in lavish terms
but the eulogy was well deserved. Maimon
profited by his studies under this renowmed
teacher, composed commentaries on the Tal-
mud, a work on the ritual, and expository
notes on the Pentateuch. He influenced his
son s mind profoundly, but in one respect
father and son differed. The son was not
unemotional but he was a philosopher first of
all. The father is all enthusiasm, full of
*(Read at the Maimonides Medical League of
New Jersey, March 17, 1931.)
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
751
faith, longing to dwell on the beautiful stories
of Hagadah, not afraid of believing in angels,
not desirous of making God an abstraction or
the apostle of God merely a deep thinker. He
was gifted with a genius for allegory, and his
images flow like a soothing stream over the
reader’s heart. His most famous work, “The
Letter of Consolation”, must have bound up
many a wound and filled with fresh courage
those who dispairingly feared that God had
forsaken His world.
His son Moses grew up in this gentle and
refined home, but his mind and soul were
trained by a father who. amid the tribulations
which were soon to follow, was upheld by the
same confidence and trust which he sought
to impart to others. Maimon’s precept and
example planted in his son’s heart a pure and
ineradicable veneration for all the tried and
traditional virtues of the Jewish character.
The law and the commandments were his de-
light. Not the less was this so because Mai-
raon at the same time instilled into him a
powerful inclination toward science and phil-
osophy. In Maimon’s home the stream of
life ran broad and deep. What was Jewish,
what was human, alike found a resting place
in the capacious soul of Maimonides.
Tire Talmud was his chosen love. The
works of Alfassi and ibn Migash were the
eyes with which he penetrated into the Rab-
binical lore. Equally devoted was the young
scholar to the various sciences expounded by
ancient Greeks, medieval Arabs and Hebrews
of all ages. Mathematics, philology, natural
science, medicine, logic and metaphysics were
included in the liberal education of the day
and all of those were the familiar friends of
our hero’s early manhood. Through the
maze of these varied pursuits, his keen, or-
derly intellect found a clear and straight path.
Knowledge was not with him a more or less
confused amalgam of discordant or disso-
ciated elements, it was one and indivisible.
And he early learned the lesson most precious
to the genuine student, that : “It is possible
for a wise man to be taught by a fool.' He
saw the limitations of astrology, for instance,
but he recognized the necessity of mastering
its literature.
But not only in the acquisition and ordering
of facts, in the awakening and development
of his great intellect, did the youthful Moses
g-row under the hand of his father, Maimon.
In this formative period, his character re-
ceived the bent which marked it throughout
life. Faith and reason, simple piety and fear-
less inquiry, saintly self-abandonment to God
and free examination of ethical sanctions and
religious dogmas — these, which are common-
ly opposite, were blended in him into an in-
separable unity. He was perfect with his God.
He was faithful to the Law of God as re-
vealed in Scripture, and to the divine reason
present in the human soul. He was true to
the spirit of Judaism when he announced as
the fundamental formula of his life the mem-
orable imperative : “Know the God of thy
father and serve him.” The tradition which
binds ages together, father to son, as knowers
and servers of the same, changeless, eternal
God is expressed in the phrase — “God is thy
father”. But something more is also con-
veyed. Knowledge and service ; not obedi-
ence with blind eyes, not disobedience with
penetrating gaze, but open-eyed obedience and
service. An earnest sense that he was born
to teach this truth to his own age and to pos-
terity seems early to have forced itself upon
him. It filled him with strenuous purpose,
but it softened while it strengthened him.
Thirteen years after the birth of Maimon-
ides, the Almohades, a Puritan sect of the
Moors of Morocco, invaded Andalusia, and
Cordova fell into their hands. The magnifi-
cent synagogues were destroyed. The Jews
of Spain were secure enough under Islamic
rule to venture on ambitious architectural
schemes. Now, the choicest products of this
art fell before the ruthless Puritans. The
schools, too, at Seville and Lucena were dis-
mantled. It seemed as though the splendid
edifice of Jewish scholarship erected by Sam-
uel the Nagicl and Isaac Alfassi was doomed
to destruction. The Jews refused to conform
to the demands of the Almohades. A few of-
fered lip-allegiance to Mohammed, but most
preferred exile to apostasy, even in outward
show. Maimon belonged to the sterner group.
He cast no stones at the weaker brethren
752
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
but himself refused to bow down in the House
of Rimmon. With his family, he wandered
hither and thither for several years, at first
settling in Port Almeria, but forced to retire
thence when the Almohades captured the
place in 1151. For 8 or 9 years we lose trace
of Maimon, but we know that he remained in
Spain without a permanent home or a set-
tled position.
The young son of Maimon never, amid all
these distractions, swerved from his ideals.
In this formative period he laid the founda-
tion of that mastery over the Rabbinical liter-
ature which he subsequently possessed to a
unique extent. As he could not carry many
books with him on his journeys, he was forced
to make his memory his library and to rely on
his own stores. The Babylonian Talmud was
not yet thoroughly interpreted, nor had the
admirable commentaries of Rashi found their
way from France to Spain. The scholars of
the earlier, middle ages, the “Geonim” had, as
Maimonides himself writes, “made fitful at-
tempts to explain the Talmud, but none of
them wrote a complete commentary, some be-
ing prevented by death, others by lack of
leisure”. Maimonides himself was destined
to a similar fate. He designed a commentary
on the whole Talmud, but his plan was not
fully realized. Still, he made much progress
during this unsettled period of his life. Be-
fore he was 23 years of age he had finished
his notes on many : ( 1 ) Massechtoth Sedarim
(the orders of books) ; (2) Moed (festivals) ;
(3) Nashim (laws of marriage, etc.) ; (4)
Nezikin (civil and criminal law) and on the
Tractate Chullim (dietary laws).
But the Talmud, though the first and chief
object of Maimonides’ devotion, was not his
only love. Among his earlier works was a
short treatise on the Jewish Calendar
(Maamer ha-Ibbur), which displayed no orig-
inality but was a clear, scientific, systematic
survey, written in Hebrew in 1158. At about
the same time he wrote a book on Logic
(Miloth Higgavon) to which Moses Mendel-
sohn subsequently added a commentary. The
same year saw the initiation of the first of
Maimonides’ great trilogy. This was the
“Commentary on the Mishnah”, which was
named Siraj in Arabic, Maor in Hebrew,
meaning “light”. This work he completed
in 1168.
In 1160, Maimonides left Spain and taking
with him his daughter and his 2 sons, Moses
and David, settled in Tez, Morocco. Here
we find many Jews leading a double religious
life on account of religious oppression of the
Puritan Almohades, and the Letter of Con-
solation, written previously by Maimon, was
presented to meet this danger.
Maimonides was about 25 years old when
he wrote in Arabic his famous letter
“Maamar Kiddush Hashem” (Essay on the
Sanctification of God). It was his first in-
cursion into public life and it placed him at
a bound among the foremost authorities of
the time. Henceforward, men recognized in
him a leader, at once statesman and enthu-
siast. Through this letter he saved Judaism
from absorption into Islam, in Fez, by per-
suading the Pseudo-Moslems that they had
not lost their inheritance in the God of Israel,
and this he followed-up by urging them to
abandon their duplicity and live openly and
wholely with God.
Owing to the effect his essay produced on
the Jewish population, especially those who
called themselves Pseudo-Moslems, Maimon-
ides was obliged to abandon Fez, and in the
darkness of the night the fourth Iyar, April
18, 1165, the family went on board a vessel
bound for Palestine. On the third of Sivan
he arrived at Acco or Acre. There he met
the dayam, Japhet ben Eliahu. He subse-
quently went to Jerusalem in company with
this Japhet and together they visited all sacred
sites and prayed at the Wailing Wall. Pales-
tine then was in Christian hands, the second
Crusade having just been over. There were
but 1(300 Jewish families to be found scatter-
ed over the entire land. They were poor in
goods and in culture, and Maimonides scout-
ed the idea of settling in an environment
where the comradeship of culture and learn-
ing was absent, so he decided to go to Egypt ;
which he did forthwith.
Arriving in Alexandria, he was presented
to the then illustrious ruler, Saladin, who,
possessing very noble qualities as a man and
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
753
as a ruler, soon became a bosom friend of
Maimonides. The Jews in Egypt then en-
joyed almost complete liberty. They were
governed by their own Nagid (Prince) who
appointed Rabbis and synagogue officials.
Spiritually, the condition of the Jews was less
satisfactory than materially. There was lit-
tle genuine devotion to the law ; there were
few men of light and leading. Karaism was
eating deep into the communal organization.
The Karaites sought to govern their lives by
the Scripture (Kara) only. To the Karaites
wTas due not the foundation, but the develop-
ment, of a true Hebrew philology. Through
his indefatigable work, Maimonides brought
back most of the Karaites into Rabbinate
Judaism, thus winning a laudable victory
which proclaimed his fame as teacher, orator
and leader.
Maimonides was deriving his livelihood
from the business in precious stones in which
his brother David was the more active part-
ner. Nothing in all that Maimonides wrote
exceeds in vehemence his denunciation of
those who lived by their learning and served
the synagogue or the school for gain. He
returns to the subject again and again; he
would have colleges without revenues and
teachers without salaries.
Soon after his arrival in Egypt, the father
of Maimonides died. This was not the only
sorrow that now visited our hero. Physical
suffering threw him on a bed of sickness,
heavy losses diminished his fortune, inform-
ers appeared against him and brought him to
the brink of death. The final blow fell when
fiis brother David perished in the Indian
Ocean and with him was lost not only their
own capital but also the money placed with
the brother by other traders. The loss of his
brother affected him sharply and etiduringly.
He did not recover from the blow for many
jyears and his letter to his friend Japhet, writ-
ten long after th®- catastrophe, bears touch-
ing witness to the close sympathy that had
united the brothers.
After the death of his brother, Maimonides
abandoned commerce in favor of medicine as
a means of earning his livelihood. His fan\e
as a physician belongs to a later period in his
career. At first he was an unknown man and
his practice was not extensive. He gave pub-
lic lectures on philosophic subjects but neither
his medical nor his tutorial pursuits kept him
from occupying his mind with the completion
of the work which he had begun in Spain in
his twenty-third year, and had spasmodically
continued by land and sea during the vicissi-
tudes of his troubled life.
The year 1168 witnessed completion of the
Siraj (Hebrew Maor) or Light, as the Com-
mentary on the Mishnah was named.
Graetz writes that the Siraj possesses clear-
ness, method and symmetry ; the construc-
tion of the Talmud seems to be opposed to an
orderly arrangement but Maimonides dem-
onstrated that this absence of system is a su-
perficial defect. The Talmud readily lends
itself to codification, if given the qualification
which Maimonides preeminently possessed.
Sometimes he dissents from the Talmudic ex-
planations of the Mishnah, in cases where
Halachah, or practical law, is affected. Again,
we find Maimonides attaching great impor-
tance to the Agadic elements in the Rabbin-
ical literature as sources of ethical and phil-
osophic truth.
In 1174. the Yeminite Jews were suffering
oppression at the hands of a chief named
Shiite Mahdi who, like the Unitarians of
Morocco, associated their purer Monotheism
with a fanatic hostility toward every other
creed than their own, and offered the alterna-
tive between Islam and punishment, many
Yeminite Jews became Moslems.
One of the best representatives of the
Yeminites, Jacob of Fayyum, appealed to
Maimonides in this crisis. In response he
dispatched his celebrated “Letter to the
South’’ (Igguth Teman), also known as the
“Gate of Hope” (Petach Tikvah). It was
written in Arabic but there are 3 distinct Pie-
brew translations. It was indeed a message
of hope. Persecution, he argued, was in one
sense a tribute to the presence of God in the
camp of Israel. “Nations envy us our pos-
session of the Law, they contend not with us
but with God. Persecutions would never
cease but Israel cannot be destroyed. Juda-
ism does not found its truth upon its miracles
754
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
but upon the historic fact of the revelation
at Sinai.” The whole moral of the ‘‘Letter
to the South” lay in the words — “Be Strong”.
The Letter to the South was not a master-
piece of reasoning but it won its victory. It
was sent to Jacob Alfayyum with the request
that it be circulated widely. Soon, Saladin’s
brother, Turin Shah, took the reins of gov-
ernment at Yemen, and the Jews were at once
relieved of their troubles and became again
free men.
The fame of Maimonides was soon in every
mouth. The Letter to the South was an epis-
tle in reply to a direct communication. Mai-
monides boasts That he never failed to reply
to any letter except when he was too ill to
write. This statement chimes in well with
the recent discoveries in the Cairo Geniza, for
many “Questions” addressed to him have
been found with his autographed answer at-
tached.
In 1174, Maimonides became private phy-
sician to the Vizir Alfadhel, and in 1177,
Maimonides appears to have been recognized
as the official head of the Cairo Jews.
“A physician”, he says, in his Siraj, “should
begin with simple treatment, trying to cure by
diet before he administers drugs”. By the
might of his genius, Maimonides assailed with
friendly hands the fastness wherein lay en-
shrined the whole Jewish lore. His victory
is chronicled in the second part of his great
trilogy in the Mishnah — Torah (Deuteron-
omy) or Yad Hachazaka (strong hand). This
gigantic work, a complete codification and di-
gest of Biblical and Rabbinical law and relig-
ion. occupied him for 10 years, but when he
completed it, in November 1180, the magni-
tude of the performance, with its 14 books
and 1000 chapters, bore no relation to the
time which he had devoted to it. To antici-
pate criticism of his exclusion and inclusion,
as well as to provide himself with a skeleton
outline, he compiled his “Sefer Haimitzvoth”
(Book of the Commandments). The list, af-
terward prefixed by the author to the Mish-
nah Torah, displays technicality, which is one
of the best qualities of Maimonides.
Richard, King of the Franks in Ascalon,
heard of the fame of Maimonides and sought
his services as his physician, but Maimonides
declined the honor. Maimonides had made
vast strides forward in medical proficiency
and repute. Alfadhel placed the name of
Maimonides on the list of royal physicians,
bestowed an annual salary upon him and
loaded him with distinctions. Maimonides
shows less originality than learning in his
medical works ; he relied on precedent and
was noted for his familiarity with the older
authorities. His medical writings, all of
which are composed in Arabic, are for the
most part summaries or elaborations of
Galen, “The medical oracle of the middle
ages”. Maimonides used experience as well
as precedent as his guide ; tested his rem-
edies by actual experiment ; recognized how
deeply physical conditions are affected by psy-
chic causes ; and maintained with a strong
touch of modernity that the aim of the doctor
is to prevent illness rather than to cure it. It
was in times of health that the patient might
most effectively prepare to meet and con-
quer the assaults of disease. Ab-del-Latiff,
the famous Bagdad physician who stayed in
Cairo for 10 years, asserted that his visit to
Egypt was in part due to his anxiety to see
3 men, among whom was Maimonides. The
poet, Alsaid Ibn Almulk, sang of Maimonides’
greatness as a doctor in ecstatic verse :
Galen’s art heals only the body
But Abu-Amram’s the body and soul
He could heal with his wisdom the sickness
of ignorance
If the moon would submit to his art
He would deliver her of her spots at the time
of full moon
Complete for her, her periodic defects
And at the time of her conjunction restore
her from her waning.
The third and last great achievement of
Maimonides is the work called “The Guide
of the Perplexed” (Moru Nevichim), a work
replete with philosophy and metaphysics.
The end came on Dec. 13, 1204, when
Maimonides died in his seventieth year. A
general outburst of grief ensued. Public
mourning was ordained in many congrega-
tions in all parts of the world. For 3 days
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
755
Jews and Moslems held lament in Fostat.
Maimonides was buried in Palestine, at Ti-
berias. In Jerusalem, a general fast was pro-
claimed. From the scroll of the law was
read the passage (Leviticus XXVI) in which
are unfolded the penalties resulting from dis-
obedience to the divine precepts, and from the
first book of Samuel the narrative of the cap-
ture of the ark of the Covenant by the Philis-
tines, concluding with the words — “The glory
is departed from Israel, for the ark of God is
taken.”
Not less of- him than of Hillel could it be
said that his gentleness, his even temper, his
modesty, were as conspicuous as his belief in
himself and his mission, his giant-like intel-
lect, his determination to make the truth pre-
vail.
CONSTIPATION*
Hilton S. Read, M.D.,
Atlantic City, N. J.
“How are your bowels; are they regular?”
“Oh, yes. Doctor they are pretty fair." “Are
they opened daily?” “Oh, no.” “How often
are they moved?” “Well, sometimes every 2
or 3 days and sometimes not for a week.”
The foregoing conversation, which I venture
to say has repeatedly taken place between
every physician in active practice and many
of his patients, is the author’s excuse for writ-
ing the following pages.
“It is astonishing and, I may say, incom-
prehensible, but nevertheless it is a dismal
fact, that even among intelligent persons, lit-
tle or no attention is paid to this all import-
ant matter of regular and free evacuation
from the bowels. I recall to mind one strik-
ing case of an exceedingly intelligent lady of
60, who told me that she had never, through-
out her long life, given a second thought to
her bowels ; when she had the inclination to
have them moved, she generally, but not al-
ways, would seek the water closet ; if the de-
sire did not manifest itself, well, no matter,
*(Read .before the Aesculapius Club of Atlan-
tic City, May 1931.)
she did not care; and sometimes, she told me,
a week or more would elapse without one sin-
gle evacuation. This is not an isolated case.
I venture to say, without fear of contradic-
tion, that there are more persons in the world
who are costive (generally through their own
fault or, at least, through want of informa-
tion on the subject), by a large majority,
than are regular.”
These are not my words, but they are on
the opening pages of a small book on “Con-
stipation, Plainly Treated and Relieved With-
out the LTse of Drugs”, written by Joseph F.
Edwards, M.D., and published in 1881. by
Presley Blakiston. I found this little book in
the Library of the College of Physicians in
Philadelphia. It is most interesting and,
though it was written for both lay and pro-
fessional circulation 50 years ago, we can all
read it with profit, even today.
So tonight we are considering an old fa-
miliar story. Old, it is certain. Familiar, too,
perhaps to a degree of holding it in contempt.
I recently questioned 20 medical students,
within a month or so of their receiving medi-
cal diplomas, if they had had the subject of
constipation presented to them in a formal
way. None of them had heard anything about
constipation except in an off-hand way in con-
junction with other conditions. Is it not pos-
sible that spread of the cults and the dis-
tressingly frequent appearance in the various
popular magazines of articles critical of the
medical profession, is due in part to the fact
that too much is left unsaid in the medical
schools? Perhaps one of the things that
should be given more importance in medical
schools and in our medical meetings is con-
stipation. In the great Library of the Col-
lege of Physicians in Philadelphia, there are
59 , volumes of varying size on “constipa-
tion"; 40 of them published outside of the
U. S. A.; most of them in London and the
second largest number in Paris ; and of 19
published in this country, 5 were published
from 1910 to 1920, 6 between 1920 and 1927,
and the remainder before 1910.
I recently had a survey made of 5 repre-
sentative drug stores in Atlantic City, which
showed that of the total number of customers
756
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
in those stores over a period of 4 days, 10%
bought cathartics.
The public is becoming, or is, toxic minded.
Thanks to the Fleischmann Yeast advertising,
the picture of the colon is now as well known
to the American people as is the picture of
the Prince of Wales or that of Babe Ruth.
Perhaps you have been impressed by the
amount of pseudo-medical advertising that
has been appearing in periodicals recently ;
particularly the advertising aimed at the re-
lief of constipation. Even the radio is doing
its bit to protect the American colon. Figures
on the Fleischmann Yeast campaign are guard-
ed jealously, but I have obtained what are sup-
posed to be the accurate lineage figures on the
1931 Flaxolyn advertising campaign. The
total of 763,981 lines of advertising to be
used in this campaign is to be distributed to
newspapers in 24 cities ; Pittsburgh leads with
139,389 lines ; Philadelphia is second with
130,038 lines ; and Boston third with 107,378
lines. Considerable of this advertising is in
papers that are supposed to censor their ad-
vertising matter. Apparently, cathartics are
considered harmless. The cults have seized
upon this combination of events, and are most
impressive to the ordinary layman because of
their “interest” in his constipation and be-
cause of the “thoroughness” of their treat-
ment. I recently saw a patient who had a
drop of blood sent to Chicago and in return
received a diet list with many, many articles
on it that she could eat or not eat, and some
of the foods I had never heard of. I hold no
brief for such quackery. But there are those
who contend, and perhaps with good cause,
that we, supposedly well-trained, honest,
medical men, are wont to turn either a deaf
or indifferent ear to the wail of the distressed,
constipated individual. It is possible that we
have been dismissing this complaint too light-
ly— with the admonition to “eat a laxative
diet consisting of lots of green vegetables and
plenty of fruit”. The layman, disgusted with
our indifference, finds plenty of instruction
for relief of his condition in the periodicals.
After following them for a while, he perhaps
drifts to the quack, who, with much gusto and
many suggestions, much instrumentation and
plenty of manipulation, promises much and
seldom delivers.
The physiologic literature, as well as the
literature of a clinical nature, is captivating.
Gastro-enterology as a whole is going through
a metamorphosis much like that experienced
by cardiology 2 decades ago. Many of the
old ideas concerning physiology of the gas-
tro-intestinal tract are making way for newer
and more exact comprehensions that bid fair
to put gastro-enterology on a more exact
plane. As yet, there is no absolute agreement
on even so important a thing as the innerva-
tion of the colon. Some physiologists ex-
plain it one way, while others take a diver-
gent view, based on what would appear to be
sound investigations and deductions. Alvarez
has done yeoman service in the correlation of
some of his advanced physiologic ideas with
clinical problems, while clinicians, like Jor-
dan, Kantor, Smithies, Brown, Eustermann,
Bargain and Paulson, and physiologists, like
Cannon, have made interesting and valuable
contributions to the subject. There is a ver-
itable maze of information — much of it con-
flicting— on the subject.
There is no possibility that I might add to
or clarify the situation. It is simply my idea
to present a limited phase of the matter in
order, possibly, to stimulate greater interest.
Commonplace medical conditions are seldom
written about and are thus apt to be accepted
in a matter-of-fact way, and at the same time
neglected. The interest of the public and the
recent developments from the various labora-
tories would seem to warrant our more earn-
est consideration of this subject. It is just
possible that we would do well to start treat-
ing patients and not diseases, and bend our
efforts to better education of the public. Per-
haps, if every constipated individual, or bet-
ter, every individual who considered himself
constipated, had been given a sympathetic, in-
telligent hearing by the first physician who
saw him, we would have fewer gastro-intes-
tinal invalids and hear less of the cults.
It would be folly to try to discuss the en-
tire subject of constipation in the time allotted
to me; that is, the subject of constipation as
generally accepted. It is a medical problem,
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
757
that needs careful analysis and study, just as
any other medical problem, and there are
many causes of it that one should consider in
a careful appraisal. We realize full well that
arteriosclerosis, mechanical interference, gall-
bladder disease, and achylia gastrica are just
a few isolated factors out of the legion of
causes. However, in our limited experience,
the chief cause of constipation has been in-
efficiency of the colon itself and it is this
functional disturbance that we will consider
tonight. Perhaps some of us have been wont
to accept a daily, spontaneously, and easily
expelled bowel movement, of a certain size,
consistency and color, as normal. But, we
must also realize that there are certain wide
variations from this average, particularly as
to frequency, that must be accepted as nor-
mal for the individual.
Constipation is certainly a disease for the
general practitioner to handle. It does not
ordinarily belong to the specialist. And so,
in discussing it, we must of necessity con-
sider it in terms of work-a-day practicability
so far as methods of examination and treat-
ment go, leaving the rarer and more special-
ized examinations to others. It is quite pos-
sible for each of us, with our ordinary office
equipment, to properly study and manage
most cases of constipation. The thing we
most often lack is the inclination to properly
investigate the condition.
The inefficient colon, which we are discuss-
ing, is inefficient either because it is overactive
or underactive, and these conditions arise either
from stimulus or lack of stimulus within or
without the bowel. Dr. Sara Jordan, of the
Lahey Clinic, in Boston, whose writings al-
ways merit unusual consideration, has done
much to rationalize our thoughts about con-
stipation. Her own and kindred writings
have caused abandonment of the old scheme
of classifying the constipated into 2 groups,
the atonic and the spastic.
The clinical history of the constipated pa-
tient must be taken with meticulous care. The
date of incidence of the constipation should
be ascertained as accurately as possible. Often
it is in the days of childhood. The dietary
habit should be noted exactly as to time of
eating, and the relation of the time of eating,
and of getting up, bathing, exercising, work-
ing and so on. The kind and amount of food
eaten and the amount of water drunk should
be noted.
It is often disturbing to find out how real-
ly harmless the patient considers cathartics or
laxatives. I have on my desk 2 pads ; one is
a prescription pad and its twin is labelled
“Medical Instructions’’. More often than
not the patient leaves without a prescription*
but he always leaves with a list of medical in-
structions, which list contains the diet, amount
of water to take, amount and kind of exercise,,
hours for retiring, kinds of baths to take, and
so on. Many times, I have been surprised to'
find, on requestioning the patient in a couple
of weeks, that he has been taking a daily or
semi weekly cathartic, quite aside from the in-
structions I had given. The excuse is, uni-
versally, that he had been doing it always and
did not think a cathartic had anything to do
with the treatment — anymore than I over-
looked telling them to brush their teeth.
Embarrassment due to the particular loca-
tion of a lavatory in an office may cause a
young clerk to deny nature’s call. Unrest oc-
casioned by failure to move the bowels on
several days, so that it got to be a phobia,
with the hourly taking of a cathartic, are
samples of what may be elicited on question-
ing. The cathartic history is always inter-
esting and sometimes enlightening.
Examination of the patient with constipa-
tion should be the usual, complete, physical
examination. Digital examination of the anus
and rectum, and an anoscopic examination,
often reveal valuable information. The com-
plete examination may bring out many ac-
companying findings of what is Icommonly
called vagatonia or sympathiconia. While
many beautiful theories have been spun about
these 2 systems balancing one another, and
that their imbalance produces constipation or
diarrhea, there is little physiologic back-
ground for such belief. The commonly ac-
cepted principle, that ingested food is ex-
creted in 24 hours, is perhaps quite wrong ; a
nearer estimate would be 48 hours. Ala-
varez has estimated that the remnants of 3
days’ meals are in each bowel movement.
The function of the colon is somewhat
758
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
similar to the condenser on the steam locomo-
tive ; bacterial action on the cellulose is com-
pleted, the water is returned to the blood, cer-
tain salts of the heavy minerals are excreted,
and the refuse is stored till ready for evacu-
ation. Many gastro-enterologists believe that
the motor function of the gastro-intestinal
tract is the important thing to study. Some-
one has pointed out that there are many du-
plications of chemical actions in the intestines,
as a safety factor, but there is only one mus-
cular tube, responsible for transportation of
the food and its end-products, from one end
of the gastro-intestinal tract to the other. The
autonomity of the gastro-intestinal tract
stresses the importance that proper defeca-
tion really begins with proper deglutition. In
other words, the very autonomity of the tract
is responsible for the fact that stresses or
strains in any section produce dysfunction
along the tract. It is like a railroad system,
where, if there is trouble between New York
and Trenton, the danger signals go up all
along the line as far back, perhaps, as Wash-
ington. It is nature’s defense. Stasis in the
colon may be evidenced by nausea. The colon
is already overworked and nausea prevents
the patient eating more and throwing more
work on the floundering colon.
A fluoroscopic examination is often quite
important, and this is within the province of
a general medical office. The deduction will
be of value, however, only after one has had
considerable experience in screen work. I feel
that since the upright position is the physio-
logic one it is the only one necessary in the
proper fluoroscopic examination of the gas-
tro-intestinal tract. It should also not be ex-
pected that a colon, loaded down with a week’s
or month’s accumulations, could yield its
standard findings when in addition to its con-
tents a barium meal is put in. So, it would
seem advisable to have the colon well cleared
out before giving a barium meal, if we are
to really study its standard performance. In
examining these patients we should also be
sure that the patient is not taking a medicine
that Would interfere with the function of the
colon under study. Reexamination with the
fluoroscope is also quite necessary.
Frequently, findings that appear to be of
serious moment, will disappear between ex-
aminations. The administration of small
glass beads, and noting the time they appear
in the stool, appealed to Alvarez as a better
physiologic test of motor function of the gas-
tro-intestinal tract. Some still use the ad-
ministration of carmine and charcoal. Com-
plete radiographic study, Wassermann exam-
ination, nose and throat consultations, and
kindred aids may be sought in study of con-
stipation, just as in the study of any other
medical problem.
The treatment of constipation begins in
childhood, by preventing its occurrence. Pre-
vention should also be continued in adult life
by educating the public to avoid fads in diet
and the self-prescribed use of cathartics.
The active treatment of the constipated in-
dividual really begins with his first visit to
the physician. If he is given a sympathetic
hearing, a complete examination, and a heart-
to-heart talk on the problem, he frequently
gains the confidence that spells success. From
then on it is a matter of complete coopera-
tion between patient and doctor, to the end
of educating the patient and his colon to nor-
mal function.
The first step often is to correct the pa-
tient’s posture. The sway-backed, pot-bellied,
or the stoop-shouldered, hollow-bellied, indi-
vidual may be greatly helped by suggestions
as to posture. Dr. Garnett, of Philadelphia,
has generously shown me some of his figures,
with which my limited series checks, relative
to the lift of ptosed organs by proper pos-
ture. His average lift of the duodenal cap is
in., and of the greater curvature of the
stomach 6-}4 in. I think it unfortunate that
less and less significance is being given to ptosis
as a provocative factor in constipation. New
standards of normal are constantly being sug-
gested and before long it is quite possible that
we will be asked to accept the pelvis as the
normal domicile for the transverse colon.
Emotion and fatigue are great factors in
the production of constipation, by producing
changes in the gradients of the colon. It is
always wise to have family spats away from
the table, as changes in the gastric digestion
Oct. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
759
are known to occur under unfavorable con-
ditions, and may be accompanied by dysfunc-
tion of the entire gastro-intestinal tract.
An important step in the treatment of con-
stipation is to forbid the use of all cathar-
tics. Sometimes this takes considerable per-
suasion. However, assuring the patient that
failure of the bowels to act for several days
will not result in a stroke, or death, is often
all that is necessary to get his cooperation.
His whole mode of living, as revealed by the
careful history, must be adjusted toward
proper physiologic action. Often he must not
only be told what to eat, but what to drink,
how and when to exercise, when to bathe, and
how to go to the lavatory. Frequently, I ap-
point an hour or hours in the schedule for him
to attempt to move his bowels. I never en-
courage grunting and straining. Sometimes
I have had blocks or a stool built that would
bring his knees quite on a level with his chin
(the old fashioned Indian squat position).
He is then instructed to massage his abdo-
men with the palm of one hand, pushing the
palm of the other hand over the course of the
colon. I know this cannot stimulate move-
ments of the colon, but it keeps the patient
occupied while taking sufficient time, and per-
haps helps the abdominal muscles. Some pa-
tients do remarkably well by elevating the
foot of the bed 8 to 10 in., and some do well
with the application of a proper belt for
ptosis. I have not seen particularly good re-
sults from use of belladonna, because the
physiologic dose often gives distressing symp-
toms elsewhere before resulting in benefit to
the colon. Personally, I think mineral oil
and its compounds are not desirable agents
because they must coat the food with an in-
digestible film, but the time of taking may
somewhat obviate this objection. Bromural
has occasionally given good results in stabil-
izing the nervous system incident to educat-
ing the colon. A morning cool plunge, with
a drink of warm water and a brisk outdoor
walk or horseback ride before breakfast, is
often helpful. I have found the administra-
tion of a large amount of water over the 24
hour period (taken in 4 oz. drinks) beneficial
in some cases of pathologic drying out of the
feces and was surprised to find a statement
in Zoethout’s physiology that the amount of
water ingested made no difference in con-
sistency of the stool.
A 20 minutes’ rest period after meals, and
an evening walk followed by a warm tub be-
fore retiring, are often beneficial. Certain
exercises, unless contraindicated, are desir-
able. A favorite of mine is a deep inhalation
for 4 counts, holding the breath for 4 counts,
and exhaling for 4 counts. Patients get so
they synchronize this with walking, and a
cycle of the exercises is complete with every
12 steps. In time, it becomes a subconscious
effort. Bending trunk on hips, twisting trunk
on hips, coming to a sitting posture without
use of the arms, alternate retraction and re-
laxation of the abdominal muscles, and bring-
ing the knees to the abdomen while lying on
the back, are just some of the exercises that
can be done for 15 minutes, more or less,,
morning and evening.
Generally speaking, I am not inclined to
use the roughage diet, having had better for-
tune with the smooth diet, but no special diet
can be used routinely. There is no pattern
that fits every constipated person. The diet,
in particular, is a personal equation. The
price of success is eternal vigilance.
There are certain patients who, on exam-
ination, show a marked anal sphincterismus
with or without hemorrhoids or fissure. The
patient with such condition sometimes receives
a most gratifying result from complete and
vigorous dilatation of the sphincter under gas
anesthesia. Removal of local lesions about the
anus is always essential to the proper treat-
ment of constipation. It has always appear-
ed to me that loss of tone in the colon, and
the resultant inability to empty itself, might
be caused by continual strife with the over-
tense sphincter. A pint enema of normal
saline may be used as often as daily, without
harm, in emptying the lower bowel. This rids
the patient of worry and any distressing
symptoms that may be caused by failure of
the bowels to act.
Certainly, it is a vastly interesting problem,
about which much has been recently learned
and much remains to be learned, and it merits
our earnest attention.
7G0
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct.. 1931
BACTERIAL HEART FAILURE
F. C. Weber,. M.D..
Newark, N. J.
When we speak of heart failure due to bac-
terial infection, we cannot interpret the title
too literally. While bacterial infection is the
cause of a heart condition which is nearly
always fatal, still the fatality may occur with-
out the heart’s showing any signs of failure.
Bacterial infection, in relation to heart dis-
ease, affects primarily the endocardium, giv-
ing rise to an endocarditis due often to known
organisms, and may be either acute, subacute
or chronic. The organisms most likely to
cause bacterial endocarditis are, Streptococcus
viridans, Streptococcus hemolyticus, Staphyl-
ococcus aureus and albus, the influenza bacil-
lus, pneumococcus, gonococcus, and meningo-
coccus. Endocarditis of rheumatic origin is
purposely omitted because the etiology of
rheumatic fever has not been definitely decid-
ed, and also because the vegetations of the as-
sociated endocarditis are bacteria-free — as is
also the patient’s blood stream.
Acute bacterial endocarditis, also called
acute malignant endocarditis or ulcerating en-
docarditis, is a secondary manifestation of
active purulent infection elsewhere. This
form of endocarditis is but one part of an
acute pyemia in which the heart lesion is
secondary to, rather than responsible for, the
systemic infection. In most cases of ulcer-
ating endocarditis, there is a primary focus of
acute infection, from which there arises a sys-
temic blood invasion, and the ulcerating en-
docardial lesion is a secondary focus from
which, again, tertiary (embolic) foci arise in
the tissues. The primary focus may be in the
uterus, lung, bones, prostate or skin. The
infecting agent is a virulent bacterium; gen-
erally the Staphylococcus aureus, Streptococ-
cus pyogenes, the pneumococcus or the gono-
coccus. Duration of the disease is from a
few days to a few weeks, for the affection
is always fatal.
Subacute and chronic bacterial endocardi-
tis are closely related ; where one stops and
the other begins is purely arbitrary. Some
writers use the term subacute, others the term
chronic ; the intensity of the disease, its pro-
cess and duration, being the deciding factors.
To simplify the subject, subacute and chronic
bacterial endocarditis will be considered un-
der the single word suggested by Libman — -
subacute — as the accepted name of a disease
having more or less the following features.
Onset is most often insidious; general
symptoms include loss of strength and tone;
sallow complexion with anemia; moderate
loss of weight ; and fever. The heart gives
evidence of endocarditis at some time or other
in almost all cases, and in the majority there
has been previous valve injury; widespread
arterial embolism takes place ; in most cases
blood cultures are positive, and the isolated
bacterium is either a short streptococcus,
much less often the influenza bacillus, and
rarely a microorganism difficult of identifica-
tion, but in all cases the microbe is of low
pathogenicity. The course of the disease is
slow but progressive, and though remissions
occur, it is, once established, almost invariably
fatal. The total duration of the illness is
from 3 months to 2 years, with an average
duration of 6 months. The postmortem find-
ings include a vegetative endocarditis on the
valves or wall of the heart, with little or no
ulceration, and wide-spread embolic infarc-
tion without suppuration. As a result of the
embolic progress, there is found a form of
glomerulonephritis more or less characteristic
of the disease.
Subacute bacterial endocarditis occurs more
frequently than we suspect. Sir Thomas
Horder, from whose paper (British Medical
Journal No. 3113, Aug. 28, 1920) much of
this material was gathered, states that about
1 in 200 patients admitted to the medical
wards of a large general hospital suffer from
it. Kinsella, in Cecil’s Medicine, states that
in a hospital of 200 beds about 4 cases a year
are seen. How frequently it is met in pri-
vate practice is hard to estimate ; depending
much upon the facilities of the observer to
properly study the case.
Of all cases, 95% are due to a nonhemoly-
tic streptococcus, the Streptococcus viridans.
It occtrs very rarely before the tenth year,
and not commonly before the twentieth nor
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
761
after the sixtieth year. Young adults be-
tween the twentieth and fortieth years are
especially affected; distribution between males
and females being about equal.
The disease nearly always attacks valves
that are already damaged, although the de-
fects may have been too slight to produce
symptoms. About J4 of all cases give a his-
tory of rheumatic fever, but between occur-
rence of the rheumatic infection and onset of
the endocardial infection there has usually
been an interval of several years, very often
years of good general health.
The invading organism comes from some
focus of infection, where we often cannot
tell, but wherever its site, teeth, tonsils, si-
nuses, gall-bladder or appendix, the process
is usually one that has caused little or no local
disturbance.
Onset is usually insidious, the patient com-
plaining of increasing lassitude, anorexia,
vague pains, chilly sensations, feverishness
and, less often, of cardiac disturbances. Fever
is, as a rule, slight at first and moderately
high and irregularly remittent or intermittent
in the later stages. Periods of apyrexia may
occur. Symptoms of cardiac involvement,
such as palpitation, precordial discomfort,
dyspnea and cough, in many cases are not
pronounced, at least not until late in the dis-
ease. Auscultation reveals a murmur, most
frequently in the mitral or aortic area. Pete-
chias appear in the skin, conjunctival or buc-
cal mucous membranes. Osier's nodes, (pain-
ful erythematous nodules, appearing usually
on the hands and feet and lasting 1-2 days)
occur sometime during the disease ; Osier hav-
ing regarded these as pathognomonic of this
disease. Embolism in the brain, lungs, spleen,
kidneys, and intestines occur not rarely. There
is progressive loss of flesh, and anemia. The
latter being often profound in spite of the
fact that the disease is due to a nonhemolytic
organism.
Blood culture is always positive sometime
during the course of the disease. The spleen
is nearly always palpable. An enlarged spleen
with a low grade fever, not otherwise ac-
countable for, should always make one think
of subacute bacterial endocarditis. The skin
may be yellowish white or, later, brownish in
color. It is common to find a small amount
of albumin, a few casts and traces of blood
in the urine, the result of the accompanying
embolic glomerulonephritis.
To make a diagnosis of bacterial endocardi-
tis, certain criteria are necessary: (1) Evi-
dence of cardiac valvular disease; (2) signs
of sepsis; (3) positive blood culture; (4)
embolic phenomena.
What of the prognosis? This formerly
was dispensed with by saying “all cases are
fatal”. If, however, we refer to Libman’s
article in the American Heart Journal (Vol.
1, No. 1, October 1925), we find much to
change this version. He studied over 800
cases, extending over a period of 25 years.
In that form of the disease which has usually
been recognized, running a course of 4 to 18
months, and characterized by fairly marked
elevations of temperature, positive blood cul-
ture and embolic phenomena, very few re-
coveries have been reported. Libman, how-
ever, in his first 150 cases of this type re-
ported 4 complete recoveries, or 3%. Al-
together, he has records of at least 10 com-
plete recoveries.
Of the fatal cases, the cause of death is
most commonly exhaustion. The myocar-
dial weakness which may be present is usually
of the type due to fever, anemia and general
weakness. At times, particularly if mitral
stenosis be present, death may occur suddenly,
preceded or not by hemoptysis (usually due
to pulmonary infarction), or by a sharp at-
tack of pulmonary edema. Embolism of a
coronary artery is a rare terminal event ; of
a cerebral vessel, a quite frequent one. The
patient may be carried off by gangrene due to
embolism of a peripheral vessel. Other im-
portant causes of death are : — polynuclear
meningitis ; subarachnoid and intraventricular
hemorrhages, which are due to rupture of em-
bolic aneurysms; rupture of such aneurysms
situated elsewhere in the body ; hyperpyrexia ;
and uremia. A complicating pneumonia or
an intercurrent or preexisting disease may
terminate life.
762
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
RELATION OF ARTERIOSCLEROSIS
TO CARDIAC PATHOLOGY*
Jacob Polevski, M.D.,
Attending Cardiologist of the Newark Beth
Israel Hospital
Newark, N. J.
There is no pathologic condition that in-
terests the cardiologist to a greater extent
than arteriosclerosis. Next to rheumatic
fever, arteriosclerosis plays the greatest role
as an underlying factor in the production of
cardiac pathology. When we consider the
fact, that the heart is only one of a trilogy
that is extremely susceptible to sclerosis,
namely, heart, vessels and kidney, then we
realize of what importance a thorough study
and evaluation of this condition is in the
proper understanding of numerous cardiac
complications.
Much has been written on arteriosclerosis,
yet the subject is far from being exhausted.
Many theories concerning this condition are
still debatable and the final word has not yet
been spoken. It is almost universally accept-
ed that chronic hypertension results in ar-
teriosclerosis, yet there are some who do not
share that opinion. This latter school ad-
mits that long continued hypertension will
produce thickening of the vessel but not ar-
teriosclerosis. The difference between thick-
ened and arteriosclerotic vessels is about the
same as between cardiac hypertrophy and
myocardial degeneration.
To consider a blood vessel as arterioscler-
otic, one must find in it not only muscular or
fibrous hypertrophy but also evidence of de-
generation such as atheromatous deposits and,
later, even calcification. All of us begin to
deposit an additional amount of connective
tissue in the media and even somewhat in the
intima after the third or fourth decades of
life. Some less fortunate show evidence of
fatty degeneration and the deposition of a
special fatty substance, cholesterol, in the
arteries at quite an early age. These fatty
♦(Read by invitation before the Medical Sec-
tion of Academy of Medicine of Northern New
Jersey on March 10, 1931.)
substances have the power to attract and de-
posit calcium. It is the presence or absence
of these fatty or calcareous changes in the
vessels of the various parts of the body, and
particularly in the intrinsic cardiac vessels,
the coronaries, that determines whether or not
a given individual will ultimately develop an
arteriosclerotic heart.
Fig. 1. Typical case of left ventricular prepon-
derance without evidence of myocardial degenera-
tion. Q.R.S. 0.08 sec. T is upright in all leads;
no notching.
One must differentiate between a heart in
arteriosclerosis and an arteriosclerotic heart.
In the former, one may find only cardiac hy-
pertrophy or dilation or both ; in the latter one
finds myocardial degeneration. It is an estab-
lished fact that arteriosclerotic changes need
not be generalized, and are frequently con-
fined to one region, and may even be limited
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
763
to one artery. Thus, we may find an end-
arteritis obliterans in one vessel, with per-
fectly normal vessels in the rest of the organ-
ism; and. that the coronaries may be the site
of sclerosis without any other artery being in-
volved, is common knowledge.
We must also divide the truly sclerotic
Group 2, in which, as the result of a sud-
den occlusion of a larger or smalller part of
a coronary tree, a wedge shaped infarct de-
velops which, if the condition does not termi-
nate fatally, undergoes gradual replacement by
fibrous tissue producing a large scar in the
occluded part of the myocardium.
Fig. 2. Case of left ventricular preponderance
with signs of myocardial degeneration. T is in-
verted in leads 1 and 2. Q.R.S. somewhat widened
beyond the normal of 0.08 sec., and slightly
notched.
hearts into 2 groups: Group 1, in which the
myocardium has been gradually undergoing
widely disseminated, degenerative changes be-
cause of the inadequate blood supply afforded
by the gradually sclerosing : coronaries and
their capillaries.
Fig. 3. Case of extreme myocardial degeneration
in a diabetic. T1 is inverted in leads 1 and 2.
Q.R.S. widened to 0.16 sec., instead of the normal
0.08 sec. and extremely notched. The degenerative
process here affected also the conducting system,
producing right bundle branch block.
We have 3 types:
(1) The heart in arteriosclerosis, with
hypertrophy and dilation due to arterio-
sclerosis in some other part of the body. The
764
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
electrocardiogram in these cases usually
shows a curve of the left ventricular pre-
ponderance. The Q. R. S. wave usually not
widened beyond the normal 0.08 second T is
upright in the first and second leads. (Fig. 1.)
(2) The true, disseminated, fibrotic heart
due to generalized capillary and arteriolar
sclerosis of the coronary tree. The electro-
Fig. 4. Myocardial degeneration in the case of
a patient suffering from angina pectoris. T is
inverted in leads 1 and 2. S-T line is below the
iso-electric base line. This is typical of cases
with coronary changes.
beyond the normal 0.08 second and may be
notched. (Figs. 2 and 3.)
(3) Localized sclerosis, or scarred heart,
following coronary thrombosis. The latter is
frequently accompanied by focal pericarditis
or the epi stenocardia of the German school.
Furthermore, the scarry part of the myocar-
dium, which is usually located in the anterior
wall of the left ventricle, frequently, under
the stress of intracardiac pressure, bulges out
Fig. 5. Case of coronary thrombosis. Electro-
cardiogram taken 2 days after attack. S-T line in
the first lead definitely below the level of the iso-
electric base line. In the second and third leads
S-T line is away above the iso-electric line and
fuses with the T curve. The tracing, in addition
to other features, presents a typical picture of
severe coronary disease.
cardiogiam in these cases usually shows, in to form a ventricular aneurysm. Cases of rup-
addition to the left ventricular preponderance, ture of such aneurysmal dilatations have been
some additional deviation from the normal, reported. The electrocardiogram in these cases
Ihe f wave is often inverted in the first or is characteristic. The S-T line is either above
second leads. If the lesion is severe, the T or below the base line. It frequently is above
wave is usually inverted in both. In very in one lead and below the base line in another,
severe cases, the O. R. S. wave is widened and assumes the typical, easily recognizable,
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
765
coronary curve. If the myocardial lesion is
severe, the T wave is inverted in one or more
leads. (Figs. 4 and 5.)
As regards the generalized sclerotic heart,
the one spoken of by European writers as
myodegeneratic cordis, or in plain English
myocardial degeneration, I feel that we are
guilty of many erroneous conceptions and
ideas. We frequently hear even cardiologists
of note use the term hypertensive or conges-
tive heart. Nothing is further from the truth
than such a conception. The hypertensive or
arteriosclerotic heart rarely, if ever, produces
a congestive syndrome. Under congestive
heart failure we understand hydrothorax,
swollen liver, edema of the lower extremities
and, finally, general anasarca. This, outside
of some pulmonary congestion, rarely occurs
in the hypertensive heart. The signs or symp-
toms of generalized congestion, or stasis, are
the ear marks of a mitral heart or of any other
case of right heart failure. To be sure, all
hypertensive heart patients are unusually free
from congestive signs. Their legs are thin
and the abdomen is frequently scaphoid in
shape. The face is usually not cyanosed but,
on the contrary, is pale and ashy gray. Con-
sistent with this observation, one is not to look
for any evidence of congestion, such as swol-
len legs or liver, as an early sign of decom-
pensation in these hypertensive arterioscler-
otic, erroneously called, congestive hearts. Nor
do these patients, at least in the early stage,
complain of dyspnea on effort during the day,
as do patients with right sided failure such as
occurs typically in mitral disease.
The earliest signs of decompensation in the
arteriosclerotic heart are nocturnal dyspnea
and night sweats. Somewhat later, one can
notice Cheyne-Stokes’ respiration not only
when the patient is asleep but even while he
is awake but ordered to close his eyes and re-
lax. Insomnia is one of the earliest signs of de-
compensation in these cases. They are also
susceptible to cardiac asthma and acute un-
derscoring acute, pulmonary edema, in con-
tradistinction to the slowly developing pul-
monary edema of slowly progressive stasis ob-
served in mitral disease, these patients fie-
quently die before any secondary right-sided
difficulty develops and, therefore, before con-
gestive symptoms become manifest. Some die
of uremia, others of cerebral accidents, and
the vast majority of cardiorenal collapse be-
fore purely back pressure congestive symp-
toms have set in. A comparatively small pro-
portion of the patients live long enough to
have the right heart secondarily involved,
with resulting typical congestive symptoms.
Recently, the question of aortic stenosis due
to localized arteriosclerosis and calcification of
the aortic valves is receiving the serious atten-
tion of cardiologists. So far, it has not been
established whether this calcification is a
superimposition on an anlage of a previous
rheumatic valvular disease, or is the logical
evolution of a peculiarly localized aortic valve
arteriosclerosis; the evidence on hand seems
to favor the latter.
We cannot stress too much this peculiar
mode of onset or early signs of myocardial
failure which is generally left-sided, nor can
we over-emphasize the fact that congestive
heart failure is not usually the final outcome
of either hypertensive, anginal or arterio-
sclerotic hearts. And, finally, that the heart in
arteriosclerosis need not necessarily be an ar-
teriosclerotic heart.
As to Treatment
There is no other medical condition where
a thorough and exhaustive knowledge, not only
of the pathology and disturbed physiology un-
derlying these conditions in general, but a
thorough scrutiny and appraisal of the
amount of pathology in a given case, is so
essential. Also, an estimation of the patient
as a wffiole, his peculiarities, his reactions, his
psyche, his environment, is paramount. Digi-
talis does not accomplish much in these cases.
Attention to diet, graded amount of effort, ex-
haustive study and attention to kidney func-
tion, particularly its concentrating power, and
a corresponding allowance of fluids and, above
all, individualization of patients, will fre-
quently bring results in cases that look almost
hopeless.
766
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
THE FEMALE SEX HORMONE*
Rita S. Finkler, M.D.,
Newark, N. J.
Work with the female sex hormone dates
back to 1906, when Dr. Robert T. Frank and
his associates initiated this important phase of
endocrine studies in Denver, Colorado. It was
interrupted for several years during the
World War and later continued uninterrupt-
edly till the present date, first in Denver and
later in Dt. Frank’s research laboratories at
the Mount Sirtai Hospital, New York City.
It was in these laboratories that I first became
interested in Dr. Frank’s work, some 4 years
ago, and ever since then I have followed the
work of Drs. Frank and Goldberger with the
keenest interest.
Some 6 or 7 months ago, I was encouraged
to duplicate Dr. Frank’s work in connection
with our Gynecologic and Sterility Clinic. I
am obliged to do the work on a very small
scale, due to lack of facilities, but the interest
and undoubted value of this work is proving
a sufficient incentive to continue.
The term “female sex hormone” was given
by Dr. Frank to the active substance found in
the ovarian follicular fluid corpus lutemn and
the placenta. It is also found in the amniotic
fluid, blood and urine of mature and pregnant
animals and humans, and may be detected in
minute quantities in certain plants and yeast.
The pure isolated hormone is a crystallin sub-
stance, chemically a complex alcohol, consist-
ing of carbon and hydrogen ; does not contain
nitrogen and is, therefore, not protein in na-
ture.
Female sex hormone produces a periodic
sex cycle, called estrus in lower animals, and
a menstrual cycle in human beings. The
periodic sex cycle in animals is evidenced by
hyperplasia and edema of the uterus and
vagina, increased secretion, cornification, and
finally desquamation, of the lining epithelium.
The phenomena of maturation can be pro-
duced at will by injecting appropriate amounts
*(Read at the monthly meeting of the Clinical
Society of Newark Beth Israel Hospital, April 8,
1931.)
of the female sex hormone into immature and
castrated animals, and the induced maturity
will continue without further injections. Hor-
mone will also produce pregravid changes in
immature and castrated animals as is evi-
denced by enlargement of the uterus and
breasts.
In humans, this hormone appears in the
blood stream periodically 10-15 days prior to
the onset of menses; increases in amount and
reaches its greatest concentration 5 to 2 days
prior to the onset of menses, and disappears
from the circulation 1 day before menstruation,
but is found in great concentration in the en-
dometrium, and in the first 5-10 c.c. of men-
strual blood. Also, in many cases of func-
tional menorrhagia and metrorrhagia it has
been found to persist longer in the circulating
blood and in the menstrual flow. These phe-
nomena have been noticed particularly in
menorrhagia of puberty, and pre-climacteric
changes presumably due to the persistence of
unruptured .graafian follicles which continue
to secrete the hormone. However, not all
functional menorrhagias and metrorrhagias
are due to over-secretion of the specific hor-
mone; sometimes these conditions are due to
under-secretion.
There are many other conditions in which it
is important to estimate the presence and the
amount of female sex hormone.
(1) In menorrhagias and metrorrhagias,'
as previously mentioned, therapy will depend
on knowledge of whether these conditions are
due to over or under-secretion.
(2) In amenorrhea and oligomenorrhea,
periodic appearance of the female sex hor-
mones in the circulating blood is frequently
demonstrated, though it is sometimes totally
absent. There are. however, cases of amenor-
rhea where an excessive amount of this hor-
mone is demonstrated periodically ; presum-
ably due to persistence of the corpus luteum,
in the following manner:
After ovulation, the graafian follicle under-
goes rapid vascularization, and formation of
luteal cells takes place, which cells begin to
produce a secretion of their own that is rapid-
ly taken up by the blood stream through the
rich capillary net work penetrating the corpus
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
767
luteum from the ovary, and at that stage the
corpus luteum appears red and is called corpus
vascularis, but it later becomes pink and as
the retrogressive changes take place, pinkish-
yellow, and finally yellow.
It is only with the onset of retrogressive
changes that connection with the circulation is
cut oft and the corpus luteum functions for a
short while as a gland of internal secretion;
its luteal cells secreting, according to some au-
thorities, 4 hormones, among which the fe-
male sex hormone has been clearly demon-
strated.
In humans and the higher type of monkeys,
the corpus luteum is indispensable to establish-
ment of menstruation; while the follicular hor-
mone causes the hypertrophy, vascularization
and branching off of -the endometrial glands, it
is the corpus luteum which accomplishes the
final preparatory changes in the endometrium
for possible embedding of the fertilized ovum.
Dr. Emil Novak calls these final changes pro-
duced by the luteal secretion the “topping off
of the endometrium”. When the ovum is not
fertilized, or fails to be embedded, the corpus
luteum undergoes retrogressive changes, thus
precipitating menstruation ; the persistence of
corpus luteum, as mentioned above, holds the
phenomena of menstruation in abeyance,
through its other hormones.
(3) In determination of sex in malformed
or pseudo-hermaphroditic persons, demonstra-
tion of the presence or absence of the female
sex hormone is most important. I am at pres-
ent taking weekly specimens of blood from
such an individual, hoping to detect the
presence of a cycle.
(4) The investigations of Corner and Hart-
man have shown that in certain species of
monkeys menstruation occurs regularly with-
out ovulation during the summer months, that
is, the non-breeding period ; these observa-
tions were made repeatedly by surgical proce-
dures and no maturation of graafian follicles
or formation of corpora lutea was demon-
strated. The explanation advanced is, that
the ovarian stroma secretes a female sex hor-
mone at those periods, or, as Dr. Emil Novak
suggests, the anterior pituitary takes on a
vicarious activity, when the ovary is inert, as
it becomes definitely hypertrophic during
pregnancy and in castrated animals.
(5) In sterile women the relationship be-
tween the amount of the female sex hormone
in the blood and in the urine is decidedly dis-
turbed: a diminished amount of the hormone
in the blood with a corresponding increase in
the urine has been definitely demonstrated by
Dr. Frank and his co-workers. This phe-
nomenon could be explained only by assum-
ing that there is a peculiarly low renal thresh-
old for the hormone in these individuals, thus
depleting the circulation of the female sex
hormone and impairing fertility. Occasionally
no hormone could be found in the blood of
sterile women with either normal or ab-
normal menstrual rhythm.
Technic for estimating female sex hormone
in the blood : (1) In menstruating women. 40
c.c. blood should be abstracted from 5-2 days
prior to the period ; in non-menstruating
women, weekly specimens must be taken for
4-5 weeks in succession, in order not to miss
the cycle. (2) The blood is mixed with 30
gm. anhydrous sodium sulphate till a dry
paste results. (3) The paste is pulverized
finely in a mortar. (4) It is extracted by
shaking in a flask with 100 c.c. ether for 10
minutes ; allowed to settle 10 minutes ; ether is
poured off into an evaporating dish; the resi-
due is again shaken with 75 c.c. ether for 10
minutes; again settled for 10 minutes, and the
second ether extract is added to the first and
left to evaporate over-night. After evapora-
tion a film of yellowish residue remains, and
this is emulsified with 2 c.c. distilled water
and injected into a mature, castrated mouse in
divided doses over a period of 48 hours.
Vaginal smears are then taken twice daily
and appearance of estrus is indicated by the
character of cells discovered: (1) Leukocytes
and mucous, negative. (2) Leukocytes and
small round nucleated cells, negative. (3)
Round nucleated cells — no leukocytes — weakly
positive. (4) Squamous epithelial cells, nu-
cleated and nonnucleated, strongly positive.
When a mouse shows a positive reaction,
smears should be taken daily for 8-9 days
longer, to make certain that there has not been
any regeneration of ovarian tissue.
7G8
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
The urine testing technic is not described
here, because it is at present being radically
modified by Frank and Goldberger and is not
ready for publication.
Testing for the female sex hormone is being
done at present in our Gynecologic Clinic with
a variety of individuals, and reports upon a
number of interesting cases will be presented
in the near future.
PRACTICAL GASTRQ-ENTERQLOGY*
J. Gerendasy, M.D.,
Elizabeth, N. J.
A careful history is still one of our most
valuable aids in diagnosis, and with such
record a provisional diagnosis can usually be
made and then confirmed or modified by other
methods of examination. Pathology in the
viscera can manifest itself in symptoms which
are truly bizarre, and nowhere more so than
as manifested in gastro-intestinal tract disease.
It is always important, in taking the history
and examining the patient, to distinguish be-
tween organic and functional diseases of the
stomach, because there are 2 distinct classes
of patients with gastric symptoms. One class
has real disease, such as cancer, ulcer or gall-
bladder inflammation ; and the other has
secondary or reflex digestive disturbances due
to disease elsewhere in the body. It is well
to remember that functional gastric disease
occurs in about 90% of the patients who con-
sult us for gastro-intestinal distress.
Inspection, palpation and percussion of the
abdomen are easy and often secure valuable
information. While x-rays may help in pro-
curing evidence necessary to make a diagnosis,
it is a mistake to rely upon them too much.
Often a test meal or a stool examination will
give more help than the radiograph ; as in a
a patient with diarrhea, where a test meal
showing achylia gastrica will give the diag-
nosis. However, let me add that a careful
history, a general physical examination, fwnc-
*(Read before the Clinical Society df the Eliza-
beth General Hospital and Dispensary, Nov. 18,
1930.)
tional tests of stomach and bowel, and lastly
the x-ray evidence, give the most accurate
diagnosis and the surest basis for treatment.
It is important in history taking not to over-
look the important psychic and emotional
causes of indigestion, particularly in women.
On the other hand, mistakes occur when
nervous symptoms such as headache, insomnia
and excitability are so obvious that one rashly
concludes the trouble is “just nerves” and
nothing else; for it often happens that func-
tional disorders, through the vears, produce
organic changes.
To evaluate the patient’s complaints, I
usually divide them into major and minor
symptoms.
Minor symptoms: (1) Epigastric distress
after meals; (2) constipation; (3) belching
gas or fluid; (4) heart burn; (5) nausea; (6)
globus hystericus; (7) transient diarrhea;
(8) transient anorexia.
Major symptoms: (1) Pain; (2) vomiting;
(3) loss of weight; (4) persistent anorexia;
(5) persistent diarrhea; (6) bleeding from
bowel or stomach; (7) obstipation.
Another aid in evaluating complaints is to
note whether the patient is of the sthenic or
asthenic habitus. The former with thick neck,
narrow hips, wide costal arch; and the latter
with long neck, narrow chest, wide hips, long
body and narrow costal arch. The asthenics
are usually slender in build and weak in struc-
ture; have functional disorders and complain
of the minor group of symptoms. They tire
easily and are malnourished and constipated,
because of relaxation of the general muscula-
ture. 4 hey usualllv suffer with the type of
ptosis which causes symptoms, and they are
constitutionally inferior. Do' not misunder-
stand me to mean that this group cannot have
organic disease; it can, on the general prin-
ciple of minoris resistentia, but for a long time
the functional disorders predominate.
I wish next to bring to your attention a
physical sign which the gastro-enterologist-
finds of great help in evaluation of subjective
pain ; the so-called “styloid tenderness”, which
Dr. Libman, of New York,: has popularized.
We know that individuals vary in their ability
to bear pain. This test of differentiation is
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
769
performed by first pressing on the tip of the
mastoid and then on the styloid process at the
angle of the jaw. Patients react to this test
in 2 ways : the pain-sensitive will wince and
jerk the head back when the styloid bone is
pressed upon ; while the pain-insensitive will
make no faces no matter how hard you press.
The normal person will react by feeling the
pressure cause moderate pain. This is a most
valuable sign, and a test purely for pain, which
does not depend on sex, race, habits or state
of health. Individuals complaining of ab-
dominal pain, who show a markedly hyper-
sensitive reaction, are very often functional
cases. Patients who are hyposensitive to this
test and who have abdominal pain are usually
found to have organic disease. Those patients
with perforated stomach ulcers who give no
previous history of gastric disturbance belong
to the latter class.
The diagnosis of gastro-intestinal disorders
has become more accurate since the introduc-
tion of x-rays as a diagnostic adjunct. The
fluoroscopic calls for a few suggestions about
when to use it :
(1) In all patients in whom serious disease,
such as ulcer or cancer is suspected, the case
history frequently throws no light to differen-
tiate gastric from duodenal ulcer.
(2) In all patients within the cancer age
who previously were well and then developed
gastro-intestinal symptoms such as persistent
anorexia, or loss of weight in the absence of
diabetes.
(3) In most patients with digestive trouble
of long standing, where systemic causes have
been excluded.
(4) In patients with severe anemia and some
loss of weight.
(5) In sudden onset of constipation or blood
in the stool, to rule out cancer of the bowel.
(6) To aid exploratory laparotomy so far
as possible, as in suspected intestinal obstruc-
tion where a plain plate will often give infor-
mation of value; also in suspected perforated
stomach ulcer where air at the dome of the
diaphragm will aid in the diagnosis.
The following case histories are taken from
the stomach clinic of this hospital, to illustrate
what has been said and other points to be
brought out as we proceed. We have ruled
out systemic disease in patients where these
are not mentioned, and have utilized the ser-
vice of all special clinics whenever necessary
to rule out reflex causes of symptoms.
Case Histories
Case No. 1. Mrs. W., aged 39, seen in the
clinic April 12, 1929, stated that since the
birth of the last child, 3 years ago, she has had
dyspepsia. For the past 4 months the symp-
toms have been aggravated by epigastric pain
which occasionally shifted between the
shoulder blades and sometimes would wake
her at night. She belches gas excessively,
after meals; has no appetite; is very consti-
pated, and has fallen from her usual weight
of 176 lb. to the present weight of 145 lb.
Her habits and marital history were negative.
Libman test, hypersensitive.
Physical examination revealed a farily well
nourished woman who probably was previous-
ly over-weight, of the sthenic habitus, tender
in the epigastrium as well as along the as-
cending and descending colon. The liver was
not palpable, nor was there gall-bladder tender-
ness. Test meal revealed no free HO. All
her symptoms being of the major group, an
x-ray picture was taken of the gall-bladder and
revealed adhesions and shadows suggesting
stones.
At operation a diseased gall-bladder con-
taining stones was removed. She did well for
6 months and then returned with almost iden-
tical symptoms and a gain of 25 lb. in weight.
After the operation, with care in diet and
bowel management, she had felt well, but then,
because of slight distress after meals, she re-
turned to her old habits of eating and the tak-
ing of cathartics, and brought back her symp-
toms. The point I wish to bring out is that
many gall-bladder operations, however neces-
sary, will be followed by a return of functional
gastric disturbance unless properly managed
as to diet and bowel care, and the prevention
of adiposity. The sequence of pregnancy and
dyspepsia, by the way, is typical of many
women with gall-bladder pathology.
I have in mind another clinic patient, 5 ft.
in height, weight 232 lb., with definite gall-
bladder history, who was so relieved of symp-
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
toms, as a result of losing 70 lb. weight, that
she refused surgery.
Case No. 2. E. Smith, colored male, aged
20, complained of pain in the left upper ab-
dominal quadrant, radiating to the right in-
guinal region for 5 days. The pain would
come after eating and be cramp-like in nature ;
associated with it was nausea and belching of
sour fluid. Had gonorrhea 8 years previously.
Examination revealed painful, swollen left
testicle.
Reflex gastric disturbance, due to epididy-
mitis, explained the symptoms.
Case No. 3. Mr. C., aged 29, white, came
to the clinic complaining of burning in the
epigastrium, and pain under both shoulder
blades. He had varying degrees of gastric
disturbance for the past 7 years. No epigas-
tric pain, but the burning comes 2-3 hr. after
meals — every day for the past 2 weeks — and
even wakes him up at night. It lasts Y\ to 1
hour, or until relieved by baking soda or food.
He has had 3 such attacks in the past W2
years. Between attacks he does not suffer. Ap-
petite good, but is afraid to eat. Has used drugs
to move his bowels for years. Drinks 4 to 6
cups of coffee a da}-, smokes 20 cigarettes and
takes alcoholics in moderation. Denies ven-
ereal disease. I.ibman test, hypersensitive.
Physical examination revealed an asthenic
type of individual with diffuse, epigastric ten-
derness, and a tender, spastic, descending
colon. No gall-bladder tenderness, and rectal
examination negative.
Treatment directed to habits, diet, and
bowtels relieved him in 1 week.
While we have no x-ray report on this
patient (usually they do not return, if re-
lieved), the typical ulcer history — of gastric
distress with remissions and exacerbations,
and food relief — leave little doubt that he
suffered from a stomach ulcer.
Another point is that here is an asthenic
individual who for years had functional gas-
tric disorder due to bad habits and constipa-
tion, and who has now developed an organic
lesion. You may have typical ulcer symptoms
without the presence of an ulcer, but due to
pylorospasm from causes such as excessive
cigarette smoking and coffee drinking, chronic
gall-bladder disease, chronic recurrent appen-
dicitis, or post-operative adhesions.
Case No. 4. Clinic patient, A. C., aged 30,
complained of stomach distress for the past 2
years, lately much aggravated. It comes as a
dull, burning, heavy distress in the epigas-
trium, and is not entirely relieved by food and
soda. Eructation of sour material and gas,
gives relief.
Physical examination showed a small round
protrusion just above the umbilicus and pain-
ful on palpation; a ventral hernia.
Here we have an asthenic individual with
ptosis of the abdominal organs associated with
simple colitis of the irritative type, and no
teeth. Because of the latter condition she
could not eat solid food, but subsisted chiefly
on coffee and cake, and so she had very little
stool. With loss of weight (from 130 to 119
lb.) the abdominal wall became atonic; and
with the natural tendency, ptosis developed.
I he atonicity of the bowel led to constipation
and tbe soap suds enemas to spastic colitis, to
complete the mischief, and give her reflex gas-
tric symptoms.
This woman was relieved bv taking solid
food in small particles; sedative drugs for tbe
over-stimulated vagus nerve; and oil by
mouth. She was relieved and gained weight.
Case Ar o. 5. Mrs. S. M., complained that
for the past 3 months she had epigastric dis-
tress after meals, belching of gas, frequent
heart-burn and nausea, poor appetite. She
feels numb and hot all over; is very nervous;
has been taking daily enemas of soap suds in
order to move her bowels, and lately noted
“white phlegm” and streaks of blood in her
stools.
The chief points of interest in her physical
examination were absence of all teeth, as-
thenic build, protuberant lower abdomen,
marked dynamic aorta. Rectal examination
showed a relaxed, boggy rectum and atonic
sphincter. Libman test, hypersensitive.
The x-rays revealed a markedly atonic
stomach pushing the transverse colon down
into the pelvis. The descending colon was re-
dundant and spastic.
Case No. 6. G. L., aged 68, male, came to
the clinic complaining of epigastric pain re-
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
771
lieved by food but recurring daily after each
meal. Condition existing for the past 4
months, with only temporary relief for a few
days at a time. Three such attacks in the past
33 years, and about 10 years apart. Since on-
set of the present attack, his appetite has been
failing progressively until now he has abso-
lutely no desire for food. Vomits occasionally
mucus or food, and is extremely costive. He
has dropped from usual weight of 165 lb. to
the present weight of 148 lb., during these 4
months.
Examination reveals a pale old man of the
hypersthenic habitus (the large framed, big
chested type) with scaphoid abdomen. Ten-
der all over the abdomen, but especially over
the colons and “cap” area of the stomach.
Muscular rigidity noted over the entire epi-
gastrium, and no mass could be felt. He had
a moderate sized left inguinal hernia. Rectum
free from tumor mass. Libman test, hypo-
sensitive. The test meal showed free HC1 20,
and no blood.
X-ray diagnosis : Scirrhous carcinoma of
pyloric portion of the stomach ; confirmed by
operation.
Here we have a man with typical ulcer his-
tory, over a period of years, and finally can-
cer. Possibly the history as given appears
simple in making this diagnosis. My pro-
visional diagnosis was duodenal ulcer or
malignancy. I have seen men of this type,
with the same history, produce an ulcer at
operation.
It is well to keep in mind that cancers and
ulcers occur in about 1/10 of the patients with
“stomach trouble”. The great majority of
dyspeptics have trouble of reflex origin — from
curvature of the spine to eye disturbances — -
and it is not sufficient to classify them as
“sour stomach”, or catarrh, or neurosis. Look
for the cause, always keeping a mind’s eye on
the systemic causes — heart, lung or kidneys.
I would also stress the point that an early
sign of gall-bladder disease is gaseous indi-
gestion, sometimes associated with loss of
weight and constipation. Remember also that
most stomach ulcers are diagnosed 10 years
too late; that is, most surgical ulcers give a
history of 10 or more years’ duration before
they arrived at operation. Any chronic gastric
disturbance, no matter how atypical the symp-
toms, associated with periodicity of recurrence
and well-being, should be under suspicion of
ulcer or gall-bladder disease.
TONSILLECTOMY BY DIATHERMY
A. S. V. Giglio, M.D.,
Elizabeth, N. J.
In 1891, Nikola Tesla first suggested the
medical use of that form of electricity which
we now call “high frequency”. In 1898,.
D’Arsonal commenced an investigation and
in 1907, Nagelschmidt, of Berlin, demonstrat-
ed that high frequency currents produced a
heating-through of the tissues and he gave
this property the name of “diathermy”. Since
then, various names have been suggested, but
as they rvere no more descriptive of the
physics involved, they have not displaced the
general approval given to the original term.
There are 2 kinds of diathermy, medical and
surgical ; the only difference being in the de-
gree of heat used, and, of course, in the re-
moval of tonsils we use surgical diathermy.
There are 2 methods of destroying tonsils,
by diathermy; i.e. electrocoagulation and
electrodesiccation, and the first mentioned is
the preferred method. It is unnecessary to
describe the whole technic, which has been,
published so often.
It is an office procedure, and is rendered
painless by painting the tonsil first with pure
adrenalin solution (1:1000) to blanch it, and
then with a solution made of equal quantities
of 10% cocain hydrochloride and adrenalin
solution. Toward the close of the treatment,
when we are nearing the capsule and the bulk
of the tonsil has disappeared, it is well to sup-
plement the surface anesthesia with a deep in-
jection of 2% solution novocain into the peri-
tonsillar region, and sometimes also into the
pillars. We use a wooden or glass tongue de-
pressor, or a hard rubber pillar retractor to
hold forward the anterior pillar, and never
turn on the current until absolutely sure of
the exact location of the needle. If there is
one point more important in the technic than
772
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
another, it is knowing where the needle point
is located. The needle is inserted into the tonsil
about Ya, to Y\ inch depth and the current,
controlled by a piston on the handle of the
active electrode, is turned on slowly. In from
1 to 2 seconds a white ring appears around
the needle. The current is then released and
the needle taken out. This procedure is re-
peated until the tonsil has been covered with
punctures dbout 1 cm. apart. The number of
punctures varies according to the size of tonsil
and the type of patient. If patient is nervous
and the tonsil small, we limit ourselves to a
few applications of diathermy, but if patient
is stout-hearted and the tonsil large, several
areas in the body of the tonsil may be coagu-
lated.
In order to minimize pain and soreness, the
operator is advised to avoid the pillars of the
fauces. For, if they are coagulated, the re-
sulting wound is stretched and irritated by
movements of the throat, in swallowing, and
pain is experienced.
As regards frequency of application, it is
best to coagulate a few areas about 1 cm.
apart in each tonsil once a week. The length
of treatment naturally depends upon the size
of the tonsils; generally about 4 to 6 treat-
ments will be required. The third, fourth,
fifth and, if necessary, the sixth treatment are
each distinctly different. One is working in
less tissue, necessarily nearer the other throat
structures, hence the need for greater care as
to depth of needle penetration, and once more
I want to emphasize the constant care needed
as to location of the needle point.
It may seem difficult to confine coagulating
measures to the tonsil, without transgressing
its boundaries, and no doubt patches of the
capsule will perish when the final tonsil rem-
nants are sought out and diathermized, but
control is easier than might be supposed, if
the needle is being used, as one can tell by
the feel when it is plunged into the tissues,
before the current is turned on, whether it is
lying wholly in the soft substance of the ton-
sil or has penetrated its harder, tougher con-
nective-tissue envelope. It will be remembered
that coagulation extends but little beyond the
point of the needle. In general, one should
avoid too extensive a coagulation at one
seance. By the foregoing method, carried out
with care, patience and perseverance, one can
destroy all tonsil tissue as thoroughly as by
surgical dissection.
With regard to scarring, after completion
of the diathermizing, if the applications have
been cautiously and accurately made, the
amount of visible cicatrization will be slight
and the pillars will retain their natural shape
and appearance; and contraction with distor-
tion and narrowing of the isthmus of the
fauces will be absent.
In the technic of electrodesiccation, the pa-
tient is prepared the same way and the same
machine is used, save that instead of using a
needle, a McFee electrode is employed and
this is connected to the uniterminal of the
high frequency apparatus or what is called the
Oudin current. The spark is tested by bring-
ing the electrode to a piece of metal held in
hand. The machine is adjusted so that it will
produce a white spark, varying between Ft
and F2 inch. The McFee electrode is intro-
duced so that its glass covering (which pro-
jects from Ft to F? in. beyond its active metal
point) touches the tonsil. The desired amount
of current having been previously turned on,
the spark is rapidly passed over the' tonsil’s
surface until the tonsil is covered with a white
film. In 5 to 7 days that white membrane will
have disappeared from the tonsil, and when
that occurs the treatment may be repeated. It
usually takes from 5 to 7 treatments, depend-
ing on the size of the tonsil. There is marked
shrinkage of the tonsil after each treatment.
Now a word about the action of surgical
diathermy in the tissues in contact with the
active electrode. Four zones can be dis-
tinguished. First of all, and nearest to the
electrode, is the coagulated zone which may
be subdivided into 2 areas, the desiccated and
the moist. In the third zone, the cells and the
walls of the blood-vessels are coagulated, but
not the blood, as the electric current generates
less heat in this layer. Fourth comes a zone
of cells which have been killed by desiccation
without being coagulated. In a further zone,
sometimes called the fifth, clinical evidence
shows that the tissues are sterilized of bac-
teria.
I onsillectomy by diathermy is not an easy,
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
773
simple and altogether safe operation in the
hands of the unskilled. One needs more than
a smattering of electrotherapy, and should
know the anatomy and physiology of the
throat, and have some appreciation of the dif-
ference in throats, and especially the very
great difference in size, shape, consistency, lo-
cation, relationship and adhesions, between
tonsils of different patients and even between
those of the same person. Until the operator
becomes skilled, the minimum current should
be used.
Some of the indications for tonsillectomy
by diathermy are: (1) Hemophiliacs. (2)
Patients with a prolonged bleeding and coagu-
lation time. (3) Cases of arteriosclerosis and
hypertension. (4) Diabetics. (5) Cardiacs
and nephritics. (6) Postoperative tonsil
stumps. (7) That group of patients who pre-
fer to endure their symptoms rather than run
the risks and discomforts of the ordinary sur-
gical operation.
There is really but 1 contraindication to
tonsillectomy by diathermy, and that is — it is
not applicable to children.
PREVENTION AND CONTROL OF
LEAD POISONING IN
INDUSTRY*
Joseph S. Mark, M.D.,
Medical Director United States Metals
Refining Company,
Carteret, N. J.
I wish to express my appreciation to the
officials of the Newark Safety Council for
the privilege of discussing this very timely
and important subject. My interest in it is
principally -concentrated upon the smelting
and refining processes and from the point of
view of the industrial physician. I fear that
I may not be able to do complete justice to
such a broad subject, especially in the brief
time allotted to me, so I shall review mainly
the principal “high-lights”. Preventive mea-
sures adopted in industry have been gradually
*(Read before the National Safety Council,
Division of Industrial Hygiene, at Newark, N. J.,
Feb. 11, 1931.)
developed within the past decade through the
work of brilliant minds and clever investiga-
tors. By their experience we may profit. My
talk will contain nothing new or startling; it
merely aims to present the lesson that we
should derive from these investigators and its
practical application in industry. A few names
immediately stand out with great clearness in
this field of work: Alice Hamilton, who made
an exhaustive study of industrial diseases in
the United States ; E. R. Havhurst, of Ohio ;
The Harvard Commission, comprising Joseph
Aub, Lawrence D. Fairhall, A. S. Minot and
Paul Reznikoff ; Legge & Goadby, Sir Thomas
Oliver, and R. M. Hutton, of Canada.
The value of prevention needs no discus-
sion, as it comes under the age-old axiom up-
on the value of the ounce of prevention.
Theoretically, it is far more simple to pre-
vent the entrance of a poison into the system
than it is to rid the system of poison and its
harmful effects. For that reason, no amount
of effort, time or money, is to be considered
improperly expended if it prevents entrance
of lead into the systems of people working
under a lead exposure ; industry is fully cog-
nizant that it is money well spent and brings
rich dividends.
Prevention of lead poisoning is a subject
of interest to the producer, the safety engi-
neer, and the physician, and can only be han-
dled successfully through cooperation of these
3 agencies. Each has his own duty to per-
form, which dovetails and overlaps, however,
to such a degree that only through amicable
understanding is it possible to accomplish sat-
isfactory results.
Skin absorption. There has been consider-
able controversy as to whether absorption
through the. skin really presents a danger.
Years ago, much stress was placed on this
avenue of entrance but recent investigators
say that the skin presents a fairly effective
barrier, and the small amount of lead which
might possibly gain entrance that way, as
compared with the relatively large amounts
entering through other avenues, is not of
much consequence. However, in order to ac-
complish perfect prevention, we should strive
even to exclude that small amount, and that
774
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
can he attained relatively simply hv measures
which are well known. Adequate washing
facility should be provided, with running hot
and cold water, soap and towels, plentifully
supplied ; and by adequate washing facilities
1 mean not only wash-stands where the men
may wash their hands, but also shower rooms
in such number that workers will not have to
wait their turn long enough to discourage use
of the bath. It should also be an inviolable
rule that men must wash thoroughly before
leaving the plant, and wash their hands and
scrub their teeth before eating, and it would
pay to supply tooth brushes and paper cups
free of charge. The men should be provided
with lockers for safekeep of their street
clothes while working and their working
clothes while off duty, and the lockers for these
2 purposes should be different ones in order
that lead dust accumulating on overalls can-
not come in contact with their street clothes.
At the United States Metals Refining Com-
pany, we have adopted a routine whereby
men’s lunches are kept in a clean, locked com-
partment. and given out by the foremen at
lunch time, only after they have thoroughly
washed their hands and teeth and put on clean
smocks provided by the employer for the pur-
pose of covering their clothes. They are also
encouraged to use scrubbing brushes for the
purpose of cleaning their nails.
Ingestion. It is an undeniable fact that,
unless precautions are adopted to the con-
trary, amounts of lead which might prove
dangerous are eaten by the workers, either
through handling of their food with grimy
fingers or keeping food in places where lead
dust can accumulate thereon ; or having lead
dust or fumes deposited on their teeth and
lips ; or chewing on a pipe, the stem of which
has proved a depository for lead or by swal-
lowing the filtrates of an abundant mous-
tache. It is worth while to make a rule that
men working in a lead hazardous position
should have no moustache or beard, or if they
have any. they should be kept closely cropped ;
and that smoking during working hours
should be discouraged.
The ingestion of lead is still not, however,
the greatest danger of absorption, for that is
easily preventable by simple hygienic mea-
sures. The most dangerous compound of lead
with the alimentary canal as its source, is lead
chloride, formed by the union of lead with
the hydrochloric acid of the gastric juice.
It is not so bad as it sounds, for the reason
that the hydrochloric acid of the gastric
juice, formed chiefly at the time of meals, is
in most cases fully neutralized by the food..
Consequently, lead swallowed during meals
is not very apt to form lead chloride unless
the gastric acidity is excessive. Lead com-
pounds, however, swallowed with the saliva
between meals, are a more dangerous risk. For
this reason, and for other reasons that I will
mention later, I am a strong advocate of hav-
ing the employer supply milk at cost, to be
taken not only at meal times but also before
starting work and, if it can possibly be ar-
ranged, between meal hours. While consider-
ing the gastro-intestinal system, we have made
it a rule in our plant to administer to each
man a weekly dose of epsom salts, in some
palatable combination, in order to insure his
having at least one thorough evacuation per
week. This fact also has a psychologic ef-
fect, as it makes clear to the men the import-
ance of keeping their intestinal evacuation in
good working order. A careful check-up is
used to see that no man misses his weekly
physic.
Respiration. Unqualifiedly, more lead en-
ters through the respiratory tract than by any
other route, and it is the most difficult ave-
nue to control. Through the lungs a very
great surface is offered for lead to enter. The
cells of the lung, if flattened out, would form
a much larger surface than is generally real-
ized, and all that surface is so constructed as
to provide for excellent absorption. It is rich-
ly supplied with blood vessels to bring the
carbon dioxide of the hlood in contact with
the oxygen of the air. If that air contains
lead dust it may enter directly into the cir-
culation. To make it a little more serious,
lead thus presented enters directly into the
general circulation. If we could find an effi-
cient way to exclude lead from the inspired
air, it would not be necessary to read this pa-
per ; our chief problem would be solved. I
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
775
do not mean to imply that we do not have to
watch lead entering through the skin and the
alimentary tract, for they do represent a haz-
ard, but I do mean to say that they represent
a relatively smaller quantity and are much
more controllable than the respiratory tract.
Lead entering through the inspired air is also
absorbed through the upper respiratory pas-
sages— the mucous membranes of the nose,
mouth and throat.
Respirators. There has been a great deal
of discussion on the use of respirators. To
be good, a respirator should: (1) exclude all
the lead and admit all the air; (2) be of such
construction that it can be worn for hours at
a time with perfect safety and comfort; (3)
and be economic and durable.
To admit air and exclude lead, the frame
must fit the face accurately, no matter what
the configuration of the face may be. This is
a big order, as no 2 faces are perfectly alike.
If air is not admitted in sufficient quantity,
it won’t be long before the mask is decorating
the forehead or the chin. The bag of the res-
pirator should be taut, for if it collapses air
will be drawn through the gaps between face
and frame instead of through the fabric.
The respirator will have to be of light con-
struction and its pressure on the face slight
and equally distributed, in order to make it
comfortable. If, in addition, by some magic
a respirator could be devised that would en-
able a man to chew on a pipe and expectorate
While wearing it, we would indeed be in Uto-
pia.
Posters calling attention of employees to
the hazards under which they are employed,
and the preventive measures they are them-
selves to use, and naming the initial symp-
toms of lead poisoning, should be displayed,
in various languages, at convenient places.
Such a poster, I will quote from R. M. Hut-
ton’s book on lead poisoning, written for the
Provincial Board of Health of Ontario. It
reads as follows :
NOTICE
Suggestions to Employees — How to Prevent
Lead Poisoning
( 1 ) All workers exposed to lead dust, lead
fumes, lead solutions and lead compounds,
are liable to poisoning. These poisons get in-
to the body through the nose while breathing,
or through the mouth when chewing, swal-
lowing, or wetting the lips.
(2) Do all you can to keep down dust.
When sweeping or cleaning, always dampen
with water, oil or wet sawdust. Where dust
cannot be kept down, you must wear a res-
pirator, which must be cleaned out at least
once a day.
(3) Eat breakfast before going to work.
Drink milk at meals, and if possible once be-
tween meals. Do not eat meals in workroom.
Leave workroom at meal times.
(4) Keep dirty fingers out of your mouth
and off your food, and whatever goes into
your mouth. Wash hands, arms and face with
warm water and soap before eating, going to
the toilet, or quitting the workroom. Clean
your lips and rinse out your mouth before
eating or drinking.
(5) A moustache must be kept short. Do
not wear a beard. Keep finger-nails clean and
cut short ; also remove loose skin about the
nails or hands.
(6) Do not chew tobacco or gum while at
work. Avoid the use of intoxicants in any
form, as they promote lead poisoning.
(7) Take a full bath, with warm water
and soap, at least twice a week.
(8) You must wear overalls and jumpers
while at work. Wear a cap if exposed to dust
or fumes. Do not wear your working clothes
outside the working place.
(9) Keep your bowels moving at least
once a day. Report to your foreman if you
notice (a) . loss of appetite, (b) poor sleep,
(c) indigestion, (cl) continual constipation,
(e) vomiting, (f) pains in the stomach, fg)
dizziness, (h) continual headache, or (i)
weakness in arms, limbs or body.
Now we come to the great duty incum-
bent upon the safety engineer, namely, the ex-
clusion of lead dust and lead fumes, to as
great an extent as possible. I do not consider
myself competent to discuss the rendering of
places of lead hazard dust-free or fume-free
— that is the sphere of the safety engineer. I
will briefly mention that this is accomplished
by rendering processes less dusty, by means of
776
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
sprinkling systems, moist sweeping of floors,
whitewashing the walls, and periodic cleansing
of work benches, window sills, machinery,
and other objects on which lead dust might
become deposited. By thorough ventilation,
plenty of windows suitably arranged, suction
fans, hoods, exhausts, and erection of flues,
we can do a great deal toward prevention of
lead dust and fumes. We can also, to some
extent, prevent the formation of fumes by
covering pots containing molten metal, espe-
cially during processes of agitation. We should
supply tappers with long, instead of short
bars, so that their faces be as far removed
from fumes as possible. Mueller, of Ger-
many, the great industrial engineer, con-
structed in his plant an apparatus on which
tappers are able to work from outside of a
closed compartment ; an ideal method.
Supplying milk at cost price, as a means of
encouraging men to consume it, has a three-
fold value: (1) It is an easily digestible and
nourishing form of food, which complements
a possibly insufficient home diet; (2) neutral-
izes the hydrochloric acid of the gastric juice;
(3) it contains calcium, which as pointed out
by Aub, in some manner helps to rid the cir-
culating blood of lead and effects its storage
in the long bones in an inert form.
Sulphuric acid lemonade. It had been the
custom in lead factories to supply the men
with sulphuric acid lemonade for drinking
purposes, instead of water, with the idea that
dilute sulphuric acid will tend to unite with
lead in the stomach to form lead sulphate,
which is comparatively difficult to absorb, but
some experimenters have shown that we
should not give much credence to that theory
and. consequently, the use of sulphuric acid
lemonade has been largely discontinued.
The reason why we need industrial physi-
cians in lead manufacturing plants is that
none of the safeguards mentioned are per-
fectly reliable, and it is not possible with our
present knowledge to exclude all lead from
the system. Consequently, I will try to out-
line in a brief way the value of the industrial
physician, but before doing so, I think that the
attitude of the industrial physician needs a
few words of consideration.
He should stand ready at all times to co-
operate with the employer as well as with the
employee. He must bear in mind the fact that
it is his principal and foremost duty to con-
serve health and to maintain life, and his ef-
forts should be bent in that direction. It is
his duty to use zeal and judgment to see that
precautions are thoroughly observed, and he
should carry his enthusiasm to such extent
that he might even interfere with the efficiency
of some of the processes employed. When he
arrives at that point he will probably be called
to order by the man in charge of production,
but a little over-lapping occasionally will cause
interchange of ideas between the medical de-
partment and the operating department, and
such discussion may be beneficial to both. Of
course, the physician has to bear in mind that
he has a duty to perform toward the em-
ployer as well as the employee, and should use
judgment and diplomacy to correlate, if pos-
sible, helpful conditions as well as efficient
production. Toward the employee his at-
titude should be one of sympathetic under-
standing. He should try to gain his confi-
dence and make him realize that the physi-
cian is there to see that health is preserved,
and. consequently, the initial symptoms of
lead poisoning should be immediately report-
ed. At the United States Metals Refining
Company we have an up-to-date system of
preliminary examination of each employee, in
order to weed out men who might be suspect-
ed of special susceptibility to lead. It is gen-
erally admitted that dark-skinned races are
most susceptible to lead ; and by dark-skinned
races I mean not only colored people, but also
Spaniards, Portuguese, Arabians, Turks, and
people from the southern part of Italy. An
interesting point about Turks and Arabians I
have repeatedly observed, is, that they have
a natural blue line on their gums. It is easily
distinguishable from the Burtonian line of
lead poisoning, for it does not come down to
the gum margin, but is still a good point to
bear in mind. People below the age of 22 are
more susceptible to lead than above that age,
and should not be employed in lead hazards.
Teeth should be in good condition, as carious
teeth and pyorrheal gums will tend to be-
come worse, and teeth even fall out, as a re-
Oct., 1931 JOURNAL OF THE MEDICAL
suit of lead absorption. Alcoholics have no
place in a lead factory, as alcohol and lead
seem to form a vicious circle. Persons with
deranged mental condition, however slight,
should not be allowed to work in lead, for it
is difficult to tell where such a condition might
merge into the beginning of a lead encephal-
opathy. People having worked previously in
a lead exposure or who have had previous at-
tacks of lead poisoning should not be accept-
ed. I wish I could tell you definitely how to
determine in an exact way what characterizes
the people who are more apt than others to
suffer from lead poisoning, other conditions
being equal, but I know of no way by which
it can be determined. We do know that un-
der identical conditions some people will de-
velop lead poisoning much more quickly than
others, and that many people can work in a
lead hazard indefinitely and never show symp-
toms of lead poisoning. During the course
of our physical examination we are careful to
keep complete records of each man’s condi-
DON’T
When things go wrong, as they sometimes
will,
When the road you’re trudging seems all up
hill.
When the funds are low and the debts are
high,
And you want to smile but have to sigh,
When care is pressing you down a bit,
Rest if you must, but don’t you quit.
Life is queer with its twists and turns,
As everyone of us sometimes learns,
And many a failure turns about,
When he might have won had he stuck it out;
Don’t give up, though the pace seems low — -
You may succeed with another blow.
SOCIETY OF NEW JERSEY 777
tion on entrance to the plant. Dfiring his
employment period, and at the time when he
leaves the Company’s employ, his records are
carefully preserved, and he is asked to sign
a statement of his history and symptoms.
Our physical examination is complete and
thorough, but we go still a little further. We
make laboratory analyses of the urine and
blood. A regular follow-up monthly exam-
ination is made of each man. Naturally, the
follow-up examinations do not have to be as
thorough as the initial examination, as they
are largely searches for changes that might
have occurred. If, in the course of a follow-
up examination, symptoms or signs appear
which are of a suspicious nature, the man is
put on outside work and carefully observed
at monthly intervals to see whether the symp-
toms were really due to lead or some other
intercurrent condition. A thorough physical
examination is given to the men on discharge,
and existing condition is checked up with that
on entrance, and is so noted on the records.
QUIT
Often the goal is nearer than
It seems to a faint and faltering man.
Often the struggler has given up
When he might have captured the victor’s cup.
And he learned too late, when the night slip-
ped down,
How close he was to the golden crown.
Success is failure turned inside out —
The silver tint of the clouds of doubt.
And you can never tell how close you are
It may be near when it seems afar;
So stick to the fight when you’re hardest hit —
It’s when things seem worst that you mustn’t
quit.
— Anonymous.
778
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
Collateral Reading
NOGUCHI
(Review by the Editor)
Noguchi ! Just one word, and a short one
at that ; being composed of only 7 letters.
One word alone, and, as used here, merely
the title of a book ; but, what a hook, and
what a man this single, seven-lettered name
stands for ! To the question — “What’s in a
name?” — one may answer that there can be
a great deal in a name, depending in large
measure upon what effort has been made to
put something there. In this instance, the
author of a biographic sketch has put into a
name — Noguchi : a fascinating story of the
life of a very remarkable man; an outlined
history of the achievements of a great scien-
tist ; an elaborate tribute of respect to a work-
er, considered by him to have been one of
“Nature’s noblemen”. And, prior to the bi-
ographer’s efforts, the human being who bore
that name through 55 years of intense living,
ere he became the subject of a biography, had
himself put into that name so much of mean-
ing that it would be difficult to find another
capable of expressing equivalents. A rose
by any other name might smell as sweet,
but Noguchi by another name would not be
Noguchi. In what ever part of the world
that name is pronounced today, and it will
doubtless remain true for many years to come,
it will be recognized as having a peculiar and
distinctive individuality. Noguchi, who came
out of the East into the West with a name of
no consequence, has all too soon “gone west”
— in a different sense — upon his last journey,
leaving a name that will be spoken with rev-
erence, remembered and honored as that of a
distinguished scientist and a benefactor of
mankind.
Gustav Eckstein, in a book entitled, Noguchi,
has produced a biography of unusual charac-
ter. It is published by Harper and Brothers,
and priced at $5 ; and we have no hestitancy
in saying that it is worth that sum of money
to any physician interested in ascertaining the
causes of disease or even merely in medical
history. From the literary point of view, it
is a unique piece of work and there are many
things about it that merit criticism, to say the
least ; many violations of literary rules that
deserve condemnation, and we are surprised
that the publishers have turned out a book so
poorly edited. Every author has a right to
employ a style of his own, but style is one
thing and gross carelessness or abuse of good
English is quite another. Nevertheless, de-
spite its serious and annoying defects of a lit-
erary character, the book has a distinctive
value, and we can overlook some of its many
faults in consideration of some of its excel-
lencies. On the whole, we think that Eck-
stein has done a fine thing, and done it in a
fine way ; allowing for his own literary ec-
centricities. Apparently, he had a difficult
subject to handle, and the fact that he has so
satisfactorily performed the task by methods
different from those of other biographers is
all the more creditable. It may be that he is
as much a genius in the field of biography as
Noguchi was in the field of bacteriology; of
that we make no pretense of ability to judge,
and we offer this limited criticism only be-
cause it seems to us a pity that such a praise-
worthy contribution to literature should be
marred by so many glaring faults — as meas-
ured by ordinary standards.
Now, returning to the matter of greater im-
portance. the book as presenting the life story
of a very remarkable member of the medical
profession, we are pleased to recommend it
for your reading. The story is of a type fa-
miliar to physicians and workers in the realm
of science: a bov born of lowly parents, and,
through the death of his father, left to the
care of a widowed mother ; crippled in baby-
hood by an accident which rendered his right
hand useless ; helped to a partial restoration
in later years by a skilfull surgeon; determin-
ing then that he would become a physician so
that he might help others ; overcoming all ob-
stacles in the way of that decision ; working
his way to the front rank of scientific investi-
gators ; making discoveries that prove to be of
incalculable benefit to humanity ; receiving rec-
ognition among and by the greatest as a sci-
entist of the highest character; then, without
any “heroics”, but with that humility which
characterizes the bravest of men only, giving
his life nobly in a final, desperate effort to rid
the world of one of the most virulent diseases.
It is not feasible in an article of this sort to
make reference to other characters mentioned
in the book under consideration, but it would
certainly be unfair in this case to omit men-
tion of one whose spiritual presence is felt on
every page. The biographer does not paint
his hero as a god ; he shows the ugliness as
well as the beauty spots, and, at times, makes
him detestable. But, all the way through, you
will feel that the mother of the hero is a living
angel.
His life ended, as he probably clearly fore-
saw that it would, in a death struggle with
yellow fever ; ended for him as a martyr to
the cause — that great cause which embodies
the spirit of preventive medicine, and would
wipe disease from the face of the earth.
Noguchi, physically, is dead; but in his
name his spirit goes marching on.
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
779
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J.
Entered at the post office at Orange, N. J., as seccnd-class matter
PUBLICATION COMMITTEE
HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J.
EDITOR:
HENRY O. REIK, M.D., P.A.C.S., Vermont Apartments, Atlantic City, N. J.
Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to
receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fact.
NOTE. — The transaction of business will be expedited, and prompt attention secured if:
All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to
The Editor, Dr. Henry O. Reik, Vermont Apartments, Atlantic City, N. J.
All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements,
or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication
Committee, (address above), Newark, N. J.
CRIPPLED CHILDREN’S COMMISSION
The General Assembly of New Jersey, in
1929, passed an Act providing for a Special
Commission to make a census of all the
crippled children in the state, and in due time
all physicians were asked to aid in that
task. The profession responded, of course,
and as one result of several conferences be-
tween the Chairman of the Commission and
the Chairman of our Welfare Commission,
with the Executive Secretary acting at times
as an intermediary,; and the State Board of
Health cooperating when necessary, a plan
was devised whereby birth certificates now
carry provisional space for recording blem-
ishes pr physical deformities of the newly
born. With a reasonably accurate census
completed, and provision made for hereafter
recording prenatal defects and birth in-
juries, the foundations are laid for recom-
mending such assistance — medical, surgical,
or financial — as may be needed by that class
of unfortunates.
Whoever conceived1 the idea originally had
a noble inspiration ; and all who participated
in developing the plan have shown a very
humane disposition. It appears further that
a considerable group of kindly disposed
citizens has indicated willingness to supply
the philanthropy which may be’ required to
restore to health or to a more comfortable
state of living, many children who would be
unable by themselves to procure proper treat-
ment or mechanical aids.
Into the General Assembly of 1931, an Act
was introduced, the purpose of which was to
replace the temporary, census-taking, com-
mission by a Permanent Commission, consist-
ing of 11 members, “to care for and to treat’’
the classified list of crippled children in New
Jersey. The proposed law specified that the
Governor, in appointing the Commissioners,
must name 1 Shriner, 1 Elk, 1 Rotarian, 1
Kiwanian and 1 Lion, at least, but, although
the Act very specifically provided for diag-
nosis and medical care of disease conditions,
no mention was made of the desirability — not
to say necessity — for including in that com-
mission’s personnel a physician or anyone
(presumably) possessed of medical knowledge.
We hope the omission was merely thought-
less ; it seems improbable that there existed
an intent to exclude physicians from a board
whose work would necessarily deal to a large
extent with medical problems. But, such
omissions have been characteristic of much
legislation during recent years, whereby lay-
men have been placed in charge of strictly
medical affairs.
In this instance, at any rate, the profession
interfered and secured an amendment to the
Act before it was passed by the Legislature ;
and in that fact we find a lesson for future
consideration. Having noted the peculiar
wording of the Act, when examining “new
bills introduced”, the Executive Secretary re-
ported it to the Welfare Committee and sug-
gested presenting an amendment that would
780
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
require the addition of a member of the Medi-
cal Society of New Jersey to the galaxy of
organization representatives already named.
His suggestion was accepted, and authoriza-
tion was given to urge such amendment. The
sponsors of the Act readily agreed to make
the alteration ; in fact, the change was made
with apparent enthusiasm. It is another proof
of the value of cooperative efforts at the right
time.
At the annual meeting, President Sommer,
after conference with the Board of Trustees,
submitted to Governor Larson the names of
3 members, from which list 1 should be
selected for appointment, as the representa-
tive of this Society upon that very important
commission. We have just heard that Dr.
B. F. Buzby, of Camden, has been chosen,
and we think this is an occasion for con-
gratulating both Dr. Buzby and the State
Medical Society.
GROWING IMPORTANCE OF MEN-
TAL HYGIENE
In her Annual Report, our Field Secretary
related the increasing interest of the laity in
her educational work, and especially referred
to the reception accorded her lectures on men-
tal hygiene, the topic which had been selected
for first place in last year’s repertoire. She
commented particularly upon the sustained in-
terest in the Society’s health talks — as show-
ing satisfactory development of our educa-
tional work — and upon the wider recognition,
by other organizations, of the instructive and
cooperative efforts being presented by the
medical profession in New Jersey. The State
Department of Education, and the Parent-
Teacher Associations, to name only 2 of the
most important organizations referred to
above, have not merely aided us materially in
providing audiences but have been very en-
couraging in urging continuance of our pro-
gram and expressing approval of the charac-
ter of information and advice that we give;
as Mrs. Taneyhill expressed it, “their effective
support has been a vital factor in our accom-
plishment.”
While adding 2 new subjects, “Common
Colds” and “Medical Quackery” (prepared
during the recent summer months), to her list
of available lectures — thus offering 7 topics
from which lay organizations may choose —
“Mental Hygiene” will probably be given the
greatest emphasis for at least another year
because of its present importance. The prob-
lem of caring for its mental defectives has be-
come in some of our larger states — in which
group we include New Jersey- — a very serious
matter. A comprehensive study of the bud-
gets of our largest, wealthiest and most en-
lightened states, such as New York, Pennsyl-
vania, Massachusetts and New Jersey, with
special reference to expenditures made on be-
half of mental defectives, will shock anyone
who is for the first time making such an in-
vestigation ; the total amount of such expendi-
ture in any one of the states mentioned, in
comparison with the sum spent for any other
single purpose, is almost unbelievable; i. e.,
the proportionate sum of money is so amaz-
ingly large. To the tax paver the problem is
becoming each year increasingly serious.
The distinctly financial aspect of the ques-
tion is not, however, the only one of im-
portance. The manner in which defectives
hamper, and the extent to which they inter-
fere with and raise the cost of our public
school plans, constitute another highly im-
portant problem. So, too, does the present
so-called “crime wave” have to be thought of
in connection with impaired mentality ; and
there we have to consider a wide range of
possibly related questions, such as heredity,
environment, education, and modes of treat-
ment or punishment.
An editorial in the Pennsylvania Medical
Journal, May 1931, discusses the relationship
of “mental hygiene to unemployment” ; which
brings out an entirely new aspect of the phy-
sician’s need for greater knowledge concern-
ing the utility of mental hygiene.
In the Virginia Medical Monthly of July
1931, the President of the Medical Society of
Virginia, Dr. J. Allison Hodges, called atten-
tion to the significance of the announcement
that “Mental Hygiene in Its Relations to
General Medicine and the Public” would be
the leading topic for consideration at his State
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
781
Society’s Annual Meeting ; commenting as
follows :
“This is probably one of the most dominant
subjects before the profession at this time, and
it is almost inexplicable that it has not earlier
aroused the attention and energized the ac-
tivities of the profession ; consequently, this
discussion should be of the greatest possible
interest to all members. To make a complete
diagnosis, as well as prognosis, of any case
that is not acute in its manifestations, is al-
most impossible without a thorough study of
the mental element in the person and life of
the patient. The family physician is more of-
ten consulted for mental and functional dis-
orders than for all other ailments combined.
There is a reciprocity of interest between the
psychiatrist and the general practitioner in the
treatment of physical and mental disorders, and
intelligent cooperation will lead to greater suc-
cess in overcoming the problems of mental
.deficiency, and solve other tasks confronting
the management and treatment of the intel-
lectually subnormal. About 13% of the pop-
ulation of the United States is intellectually
subnormal or composed of retarded individ-
uals, who nevertheless may be apparently so-
cially adequate, and the situational factors in
these borderline cases must be thoroughly
studied so as to be correctly interpreted. If
these patients, who are frequently involved in
antisocial behavior are correctly estimated in
earlv life, the results leading to crime and de-
linquency may be largely averted.
Psychiatry is no longer the ‘step-sister of
Medicine, but a respected member of the
family of the medical arts and sciences’, and
it is our professional duty to recognize such
a fact and prepare general practitioners as
well as specialists and internists to cultivate
a skill and interest in the early recognition
of mental disease and personality disorders
in children, so that our civilization may be
advanced, while at the same time it is pro-
tected by full knowledge of all of these as-
sociated factors in private and public life.
We welcome an opportunity that will pop-
ularize this mode of thought and action, and
believe that this discussion will open new
fields of investigation and research work for
many who have not heretofore considered this
subject.”
All in all, we think our Field Secretary has
acted wisely in giving her “Mental Hygiene”
lecture so prominent a place in our public
educational program, and anticipate that the
profession as well as the public will profit
largely by her work.
AN APT PHRASING OF MEDICAL
ETHICS
In the opening session of the House of
Delegates, at the Asbury Park meeting, in the
course of presenting important correspon-
dence, Secretary Morrison read a letter which
he had dispatched to the Secretary of the
American Medical Association, Dr. Olin
West, in response to the latter’s request for
an opinion upon an ethical problem which had
been presented to the national organization.
That problem was — whether the Principles of
Medical Ethics should be so amended as to-
remove existing restrictions and make it ethi-
cal for physicians to obtain patents on instru-
ments. appliances, methods of production of
therapeutic products, and on medicinal agents
used in the treatment of disease.
Dr. Morrison’s response, read to and en-
dorsed unanimously by our State Society, and
published in the Transactions (Aug. Sup., p.
5), merits the announced expression of ap-
proval and deserves to be read by every mem-
ber of the profession. Lest it should become
buried in the records, and thus escape the no-
tice of some members, we take this means of
directing toward it your special attention. He
said :
“I believe that the members of the Medical
Society of New Jersey would vote, by a very
large majority, against permitting a physician
to receive, under our code, a patent right on
any instrument, appliance or remedy to be
used in the alleviation of human suffering.
Such action, if endorsed by the profession,
would not only favor that tendency toward
commercialism which has recently threatened
to become rampant in our ranks but would
submit us to further adverse criticism by the
laity. Why should anyone be permitted to
commercialize pain, or sickness, or the rem-
edies for suffering? Our position differs from
that of the mechanic or manufacturer who in-
vents or produces a time-saving device or a
labor-saving machine ; we cannot apply their
business principles to our dealings with hu-
man lives. The past history of medicine is
'782
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
illuminated by the names of medical heroes
who have given years of toil, and even spent
of their own substance, in efforts to reduce
human suffering. What glory would have at-
tached to their names had they wrung from
sufferers exhorbitant royalties in payment for
their discoveries?
As a practical application of the principle,
consider the construction of the Panama
Canal. Would that piece of work ever have
been completed, if the builders had been com-
pelled to pay the royalties of patent rights
upon the means of controlling yellow fever?
Certainly not l Or, think of the prevention
and cure of diphtheria, the means for which
are now at the command of every municipality,
in the world, and consider whether that would
have been true if the results of scientific work
with that disease had been patented. Or,
again, would it be in keeping with the ideals
of the medical profession, to compel one phy-
sician to pay financial tribute to a fellow phy-
sician for some instrument or remedy the lat-
ter had discovered?
Think ! The Great Physician might have
made himself the richest man in the world’s
history, had he put a monetary price upon his
prescriptions for salvation.
No! We still approve of keeping in the
•code that section which provides — It is un-
professional to receive remuneration from pa-
tents for surgical instruments or medicines;
or to accept rebates on prescriptions or sur-
gical appliances, or perquisites from attend-
ants who aid in the care of patients.”
Aside from being an expression of the
Secretary’s personal opinion, and later a rec-
ommendation from this state society, Dr.
Morrison’s letter constitutes a timely remin-
der to members of the medical profession — in
an age when, perhaps more than ever before,
a man’s financial rating is the measure of his
success, and when the temptation to convert
personal knowledge or skill into gold is cer-
tainly greater than in former times — that ad-
herence to our self-imposed, idealistic prin-
ciples of conduct is yet the brightest gem in
the physician’s crown.
Medical Ethics
CHARACTER— DECENT CONDUCT
(From The Kalends, Williams and Wilkins
Company.)
Was it not Shakespeare who caused Cassius
to say: “Upon what meat doth this our Cesar
feed, that he is grown so great?” Gentle Will,
although taboo to modern unco guids because
of his reputed fondness for brown October
ale, knew r^astly more about life than do the
godly elect who foolishly quench their thirst
with insipid water. The Bard of Avon put
into the mouth of Cassius a question which
is pertinent today, for many there are in this
broad land of ours who are afflicted with
superiority complexes.
Throughout America, in the nation, in the
state, in the city, in the village, in the office,
in the shop, and even in the American Mer-
cury, are found those who feel superior to
their fellows, and we lesser folk wonder, as
Cassius did about Cesar, how and by what
right they get that way.
The desire to appear superior is universal.
It is not restricted geographically, politically,
or socially. Like hooey, it may be found
everywhere. What to do? For the benefit of
the largest number would it not lie fair to
establish a standard by which all men and
women might be measured honestly to deter-
mine whether they are or are not really su-
perior.
What should such standard be ? Wealth ?
Birth? Intelligence? Education? If one of
these, why ?
Wealth is not a proper standard because
the wings of wealth are proverbial, and a
standard must be enduring. Also, the mere
possession of wealth may be strong evidence
that its possessor is a damned scoundrel. No,
wealth as a standard of worth must be quickly
buried in quick-lime to prevent a stench.
Well, how about birth, so long accepted as
a standard of excellence ? Certainly no man or
woman desires credit for being born; it is
patent that not one of us is consulted about
it. The basest-born “enjoys” that experience
in common with the bluest of blue bloods.
Then, too, is it not true that many of the
haut ton have ended their careers in felon’s
graves? No, accident of birth cannot be a
standard, for a standard of worth must hold
true in all cases.
How about intelligence and education?
Surely, it might be assumed, intelligence plus
education is an index of superiority. Possibly
so, in a few instances, but how account for
the intelligent and educated rascals with which
Oct., 193 L
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
783
our jails are filled, and for the vastly larger
number of such rascals which the commonalty
secretly envies because of their ability to es-
cape incarceration? That is, the ability to “get
away with it”. No, intelligence and education
have little to do with real worth. Criminals,
rakes, and roues are seldom .simpletons.
What then remains as a standard with
which to judge men? Is there one? Yes, a
primal one. One that is too often forgotten —
that of decency. All men, rich or poor, high-
born or of low degree, educated or unedu-
cated, stupid or intelligent, all can conform
to this standard if they will. Before such a
standard all men meet upon a common ground,
and it is a standard which is fundamental and
not subject to change. The truth residing in
Pope's lines is eternal : “Honor and shame
from no condition rise ; act well your part,
there all the honor lies.”
ROADSIDE ESTHETICS
(Editorial. New York Times, July 23, 1931.)
It is good to learn from the American Civic
Association's current bulletin that something
is being done to preserve roadside beauty.
California has lately destroyed 50,000 objec-
tionable billboards along her highways. “Now,
when we invite our friends to come and see
the wonders of the world”, says The Los
Angeles Times, “there is reason to hope that
we will not have to conduct them down a dark
alley of ads.” Maryland hotel men have agreed
to discontinue this form of advertising.
Others could afford to follow their example,
since a lurid sign must repel at least some
prospective patrons. Much recent legislation
is aimed at the growing nuisance of the auto-
mobile “graveyard”; the industry itself is at
last giving attention to that problem. In Mas-
sachusetts the Supreme Judicial Court now
has before it the long-awaited special master’s
report dealing with the local billboard law.
“Beauty in the sense intended and employed
in the framing and administration of these
rules and regulations”, the master says, “has in
fact a real and substantial economic value to
the Commonwealth.”
His findings may ultimately be debated be-
fore the Supreme Court of the United States.
But it will be a long day before roadside es-
thetics can rest on regulation alone. Zoning
may in time stretch its mantle over them, tax-
ation may help to drive out of business those
who would destroy them, here and there an
advertiser may cooperate, but the final arbiter
must be public taste. America may be reviled
for her slovenliness by critics from other
countries — a German author calls her a “Bill-
board Paradise” — but she is not the only sin-
ner. In the introduction to the year book of
the British Design and Industries Association,
Clough Williams-Ellis indicts the civilization
which is “fouling its own nest” and desolating
the English countryside. Desecration has not
gone so far there as here. Rural regions re-
main something to be walked over and not
whizzed by. To our score of hikers aiong,
say, the Green Mountain Trail, Devonshire
has its hundreds — even if they must dodge,,
now and then, the trippers in their chars-a
bancs.
In Lighter Vein
Odd that the King of Siam had to come to the
driest country on the globe for an eye-opener. — ■
Ohio State Journal.
A White Plains church holds service for golfers
at 8 a. m., but we think that is a serious mis-
take. Golfers need service more after the game
than before. — Albany Evening News.
What we should like to know from Professor
Piccard is whether the clouds, viewed from the
other side, showed any silver linings. — Virginian-
Pilot.
Any rum racketeer in the big cities is in the
near-bier business. — Arkansas Gazette.
Not Now
Isaac (to Abie while bathing) : ‘Abie, can you
float alone?”
Abie (impatiently): “Dun’t talk beesnuss now,
Isaac. Call me at the office tomorrow.”
Quick Trip
First Angel — ‘‘How’d you get here?”
Second Angel — "Flu.”
So
Mrs. Nodimes — “Is your husband tight, like
mine?”
Mrs. Nickless — “Is he? Say, every time he takes
a penny out of his pocket the Indian blinks at the
light.”
[Little Surprize
“Joe has a glass eye.”
“Did he tell you that?”
“No; it just came out in the conversation.” —
The Wampus.
Accident to an Optimist
Waitress — “Oh, I'm sorry I spilled water all
over you.” Patron — “That’s perfectly all right, the
suit was too large anyway.”- — Drexel Drexerd.
Bloom Still On
“Eliza’ , said a friend of the family to the old
colored washer-woman, “have you seen Miss
Edith’s fiance?”
“No, ma’am'1, she answered, “it ain’t been in
the wash yet.” — Jack-o’-Lantern.
784
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1031
Lighthouse Observations
WHY WE REACH FOR THAT SWEET
In the Journal of August, 1930 (page 691), we
presented in this column the report of some in-
vestigations concerning the value of sugar as an
emergency stimulant. Under the caption — Cake
for Tired Working Girls — evidence was submitted
in support of the natural craving for sweet meats
and of the fact that waning energy can be re-
vived rapidly by an intake of sugar in any form.
This month we are copying from the Literary
Digest of June 13, 1931, another reported experi-
ment, the results of which indicate that the boy
or man who desires 2 desserts with his dinner is
not by virtue of that fact alone — an imbecile. The
report follows :
Take one small boy and place before him two
dishes, one filled with spinach and the other with
cookies such as_ grandmother used to make. Leave
the room and try to guess which of the dishes will
be empty when you return. Will the boy reach
for a sweet or a vitamin?
This simple experiment is sketched by The Lab
Log, of Colgate University, Hamilton, New York,
in its record of a series of reports just completed
by 2 groups of research workers in the Hamilton
psychologic laboratory concerning the factors in-
volved in every-day eating. That small boy, it
seems, is no exception. Everybody naturally
reaches for a sweet. Sweets stimulate the flow
of gastric juices.
The “inside information” is given in The Lab
Log:
“Many balloons have been swallowed and not a
few miles of smoked paper have passed over
kymograph drums, recording stomach contrac-
tions, flow of saliva, and the response of gastric
juices.
Measurements of the latter have perhaps fur-
nished the most sensational data on the psycho-
logic reaction to foods. The rate of gastric secre-
tion was determined by chemical analysis of
samples obtained from, the stomach. The subject
ate a test meal, and at 15 minute intervals a
sample of the stomach contents was secured
through a tube. Analyses showed that there is
some slight increase in the secretion of gastric
juice from seeing, smelling, or thinking about food.
The really significant increases, however, resulted
from tasting food. Sweet desserts gave the great-
est secretion, with meat running second. It was
found that salty tastes stimulated to a slight
degree the gastric juice to flow, while bitter or
sour tastes have no effect. Sweet tastes are by
far the greatest stimulators of gastric juices, and
of all sweets a chocolate bar was found to have
the greatest effect. Chart records indicate that
the gastric juice begins to flow as soon as the
first taste of food reaches the mouth, increasing
steadily until, within about 1 hour after dinner, it
reaches its peak, diminishing rapidly after that
time.”
Between 1 and 2 hours after eating a normal
meal, the Hamilton account adds, the natural flow
of gastric juices approaches the vanishing-point.
But unfortunately all the food in the stomach had
not been completely digested by this time, and
more gastric juices were needed. It was found
that:
“Sweet taste acted as the greatest stimulator,
and in order to bring the gastric flow back some-
where near the level it attained during the meal.
further sweets were given. The results were im-
mediately obvious.
It is therefore possible to draw the conclusion
that a second dessert, taken 1 hour after dinner,
or a few pieces of candy or some sweet cakes,
are not only pleasant aftermaths to the dinner
but also a valuable psychologic aid to digestion.
The records also permit the conclusion that a
sweet taste during the course of a meal — such as
sherbet with the heavy course — will help to keep
the flow of gastric juice up to full requirements.
Records of stomach contractions while the
stomach is at work digesting food show that salt
and bitter tend to inhibit these normal contrac-
tions, while sweet and sour have a practically
negligible effect. The stomach contraction ap-
paratus and saliva recorder were used in this
work. Sweet and salt tastes had a generally stimu-
lating effect on the flow of saliva, while sour and
bitter caused a brief spurt, followed by a diminish-
ed secretion.
The elementary tastes of sweet, sour, salt, and
bitter have been used for the experimentation so
far, although some work has been done with com-
plicated foods.”
Public Relations
MEASUREMENT OF NOISE
(In the August Journal we published an or-
iginal article entitled “The Noises of Civilization
and Their Evil Effects”, by Dr. Walter A. Wells,
a distinguished American otologist, and a copy
of the Journal having reached us in Lucerne,
Switzerland, we had just looked it over once more,
in printed form, when we fell upon a somewhat
facetious editorial in the London Times of that
day, September 3, which we herewith reproduce):
We have all heard of noise. At quite an early
stage in our earthly pilgrimage a special connec-
tion between noise and ourselves was more than
hinted at, and as the years have passed we have
gradually changed from being accomplices to
being judges. It is one of the privileges of being
grown up to be able to adjudicate upon noise, and
to declare that it is intolerable and simply must
be stopped. It is a comfort in middle age to have
science upon one’s side, and to hear that the
instruments have been invented which can
measure noise exactly. No longer will it be pos-
sible for the more self-assured of the young to
enter the room with blatant lies upon their lips,
denying that in fact they were making any par-
ticular noise. The men of science now know how
to measure noise with extreme exactitude, and
recently Nature had an article from the pen of
Dr. Kaye, the noise-measurer, which tabulates
all noises which must put a man off his work,
from the rumbling of a tramcar to the snarling
of a Bengal tiger. Perhaps the greatest of all
the afflictions of a loud noise is that it prevents
one (and we have all been one in our time) from
hearing oneself speak. One has protested after-
ward at noise so unmannerly, and one has been,
perhaps, disbelieved. Now science has produced
measurements, and can show incontjrovertibly
that above a certain pitch of noise the human
voice simply cannot be heard.
Noise is so real a menace to life today that
a special means of measuring it has had to be
invented, a means called decibels, by which in-
tensity of noise can be measured. Seventy dec-
ibels mean that 7 noughts follow, that is to
Oct.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
7S5
say that the intensity is 70,000,000 strong, while
30 decibels mean that no more than 3 noughts
follow — a paltry 1000 intensities of vibration.
Armed with this measuring rod, so well suited
to geometric progression, the man of science can
prepare his tables and can show that whispering
is really very much more polite than thunder
or church bells, because whispering, when
measured at a distance of 5 ft., yields 10 to 40
decibels of noise, while church bells yield 60 dec-
ibels, and thunder 6 5. Thunder is just the same,
in the eyes of science, as the dog barking, which
is also 65 decibels, but science shows that we have
reason to be thankful for our dogs, and for not
living in the jungle, because the Bengal tiger
snarling at a distance of 15 ft, registers 75 dec-
ibels, and the Siberian tiger roaring, no less
than 7 ft. away, registers 80 decibels, while a
lion roaring (in the New York Zoo at 18 ft.)
has no difficulty in showing 8 5 decibels on the
score. This last figure is exactly the same as
the figure yielded by Niagara Falls when tested
at the loudest spot. Such noises are, as is only
to be expected, considerably less than some noises
very much more familiar. The pneumatic drill,
which we all hear in the streets, registers 90
decibels, or 9,000,000,000 intensities, and so does
the printing press room in whose proximity
journalists do their deep and thoughtful work
and formulate their judgments upon the state.
As for aeroplane cabins (“at least a thousand
times noisier than an express train”, says the
report), the noise inside them is anything from
80 to 110 decibels, intensities of noise so shatter-
ing that they explain immediately why so many
people ride in aeroplanes once, and no more
than once.
Where the new measurements are likely to
prove particularly valuable is in those chronic
railway carriage controversies. Victory will now
rest with the traveler who knows his science.
It has been established that opening the carriage
window increases the sound by 5 decibels for
every 10 miles an hour in the speed. One of the
chief methods of measurement in use is to col-
lect the sound in a cloth and then to measure the
amount of heat generated, a method which pre-
sents some difficulty when it is desired to place
upon permanent record the degree of angry loud-
ness of some dissatisfied visitor, whose lack of an
accommodating spirit further shows itself in an
unwillingness to give an encore for the benefit
of science. But, though there are these troubles
in individual cases, noise is such an intimate
friend today that we must be glad of any news
of how it is getting on, as it undoubtedly is.
Even if the measurements seem strange and do
not seem to allow enough for sheer aggravation,
at any rate it is much to know that we are on
measuring terms with something which plays so
great a part in all lives.
School Health Department
CAFETERIA AND LUNCHEON
Allen G. Ireland, M.D.,
Director of Physical and Health Education, State
Department of Public Instruction, Trenton, N. J.
Sanitary measures are essential in a school
cafeteria or lunchroom. The health of food hand-
lers should be beyond question. An annual ex-
amination of these workers is important. Food
handlers should be given printed instructions con-
cerning their part in a prevention program. They
should be cautioned about coughing over food;
about the use of the hands while serving, and
about the selection of foods to be served.
The methods employed in washing dishes and
utensils should be carefully studied to insure abso-
lute safety. The school physician and the health,
officials can advise on this point.
Milk used at school should be of high standard
and purchased from a reliable dealer. Precaution-
ary tests annually are advised. Grade A pasteur-
ized milk from tuberculin-tested cattle is a good
standard for schools.
Need and Scope of Records and Reports
(1) To record pupil health status, hence, pupil
health needs.
(2) To make the health findings available to
parents, teachers and others working
with the pupils.
(3) To measure results.
(4) To facilitate cooperation between the health
department staff and the administrative
and teaching staff.
(5) To estimate from day to day the incidence
of communicable disease and to properly
account for absences, exclusions and
readmissions.
(6) To record health service rendered.
(7) To establish a guide whereby the efficiency
of the staff can be estimated.
(8) To furnish the administrator with a sta-
tistical picture of accomplishments and
needs for administrative or publicity pur-
poses.
(9) To record the sanitary conditions and needs
of buildings and equipment.
(10) To account for costs of school health de-
partment.
(11) To obtain permission for treatments.
(12) To provide duplicates of certain forms in the
language predominant in the community.
Standards
(1) Uniformity throughout the system.
(2) Permanency of individual records for dura-
tion of the pupil’s school career.
(3) Simplicity but in necessary detail.
(4) Availability to those using them.
(5) Accuracy, neatness and legibility.
(6) Utility.
Follow-up Procedure
Any measure supplementary to the health ex-
amination and which uses the findings of the ex-
amination as the basis for adjustments, correc-
tions and recommendations in the interest of child
health and education.
Notification of parents by one of several meth-
ods.
Home visitation by physician, nurse or teacher.
School visitation by parent upon invitation to
confer with physician, nurse or teacher.
Periodic reference to records to renew correc-
tive efforts with needy cases and to measure re-
sults.
Systematic reference of examination findings to
the teachers together with explanations and
recommendations concerning adjustments and
management in individual cases.
Motivation of health training and instruction
through the study of individual and group needs
as revealed by the examination.
Adjustment by the principal of programs,
schedules, pupil load, extracurricular activities.
786
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
etc., when shown by the composite findings of the
examination to be needed.
Home cooperation secured :
By letters and literature.
By visitation.
By general publicity.
Through Pai-ent-Teacher Association.
Cooperative arrangements with clinics, hospitals
and specialists whereby special examinations and
tests may be insured for selected needy cases:
Psychiatric and psychologic.
Urine; sputum; blood.
X-rays and fluoroscopic.
Personal conferences with pupils.
Discussion conferences with classes or groups
having similar needs.
Woman’s Auxiliary
WOMAN’S AUXILIARY TO THE AMERICAN
MEDICAL ASSOCIATION
(This report is, by special permission, reproduced
from the Journal of the Indiana State Medical
Society, July 1931.)
Again it is the pleasure of this writer to review
the high points of another annual session of the
Woman’s Auxiliary to the American Medical As-
sociation; this time, the ninth, was held in Phila-
delphia, June 8 to 12. It was the first time that
the Woman’s Auxiliary was in complete charge
of the entertainment for all visitors, members of
the families of physicians. Highly successful were
the arrangements for the Auxiliary meetings at
the Bellevue-Stratford Hotel, and the entertain-
ments, fulfilling the hopes of the Convention Com-
mittee (made up of women from Pennsylvania,
New Jersey and Delaware) that we “carry away
a vivid impression of Philadelphia as a great medi-
cal and cultural center, and a city abounding in
hospitality”.
The official Auxiliary program began Monday
with a luncheon in honor of the Auxiliary presi-
dents, followed by a round table conference on (1)
program for county auxiliary meetings; (2) the
technic and value of a committee on public re-
lations; and (3) history and archives.
The National Board dinner at 6 o’clock preceded
the pre-convention Board meeting with the Presi-
dent, Mrs. J. Newton Hunsberger, Pennsylvania,
presiding. Short reports were given by officers
of the Auxiliary and chairmen of standing com-
mittees. The budget and proposed changes in
the Constitution were discussed, and the nomi-
nating committee elected.
The general meeting on the Roof Garden of the
Bellevue-Stratford Hotel began at 9 o’clock on
Tuesday. After singing “America”, the invocation
and an “In Memoriam’’, with the audience stand-
ing, Mrs. Hunsberger read the Presidential Ad-
dress; its record of untiring labor and accomplish-
ments, stressing the value of personal contact,
elicited much applause. Mrs. Harry C. Podall,
of Pennsylvania, Corresponding Secretary, read of
the clerical work involved in this growing organ-
ization.
Mrs. Fred L. Adair, of Illinois, Treasurer, re-
ported bills paid and more than $2000 in the
treasury.
Mrs. Southgate Leigh, of Virginia, First XTce-
President and chairman of organization, told of
the division of territory among the 4 vice-presi-
dents, and the 4 surveys prepared during the year
and sent to editors of state journals for publica-
tion; the formation of a state auxiliary to the
North Dakota Medical Association, which makes
38 states in the process of organization, with New
Hampshire and New Jersey completely organized;
the 12,494 paid members in 9 years represent a
victory for ardent workers, especially when one
considers the difficulties in perfecting auxiliaries.
The report of Mrs. E. V. DePew, of Texas, chair-
man of the Program Committee, was read by
Mrs. A. T. McCormack, of Kentucky. Reference
was made to the popularity of the study envelopes,
particularly the one on “Communicable Disease
Control”, which is used not only by auxiliary
groups but by other women’s organizations. Sev-
eral states have their own study programs pre-
pared by their medical associations; among these
are Oregon and Illinois. It also was brought out
that — “Aggressiveness on our part defeats our
purposes,”
The report of Mrs. Elmer L. Whitney, of Michi-
gan, Chairman of Legislation, was read by Mrs.
McCormack. Mrs. Whitney urged county presi-
dents to have 1 meeting devoted to legislation in
order to educate members as to movements of
vital importance to the medical profession, say-
ing: “If each of our 12,000 members were well-in-
formed, we would be of incalculable strength.”
Mrs. T. O. Freeman, of Illinois, Chairman of the
Finance Committee, gave a black-board comparison
of expenditures of the outgoing administration
and the present budget. Mention was made of the
Auxiliary playing cards, the back of which are
decorated with the “better half of the caduceus”
—our official insignia.
Mrs. A. Haines Lippincott, New Jersey, Chair-
man of the Public Relations Committee, reported
a comprehensive study of the opportunities for
service awaiting well-informed auxiliary members.
Mrs. R. N. Herbert, of Tennessee, Chairman of
the Hygeia Committee, reported sending out over
3000 pieces of mail; that 110 auxiliaries had sent in
their quota of subscriptions; that there were 325
more auxiliary subscriptions than last year: that
Tennessee had a Hygeia float in the May Day par-
ade. Mrs. Herbert gave radio talks featuring
Hygeia, and read a paper on “Educate with
Hygeia” before several audiences.
Mrs. Wayne Babcock, of Pennsylvania, Chair-
man of the Revision Committee, read the changes
suggested by the committee and recommended
from the pre-convention board meeting; they were
adopted.
Mrs. John O. McReynolds, Texas, Chairman of
Press and Publicity for State Journals, expressed
her appreciation of the cooperation received from
State Society Journal Editors and the response to
questionnaires sent out — many of the answers
will be put into form for study and enjoyment.
Mrs. Walter Jackson Freeman, of Pennsylvania,
Editor for the American Medical Association Bul-
letin, reported 9 letters containing accounts of ac-
tivities over the Auxiliary world. She said, too:
“I always stressed some phase of the convention
plans to create interest.” (Over 1100 women regis-
tered at the convention.) Furthermore, the sub-
scription to the Bulletin is only 50 cents. Mrs.
Freeman was in charge of the distribution of treas-
urers' receipt blanks; 1000 books were ordered,
831 used; she advises presidents to have a supply
of these for state meetings.
Mrs. Edgar S. Buyers, of Pennsylvania, Chair-
man of the Printing Committee, reported expendi-
ture for booklets, programs, etc.
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
7 ST
The Historian, Mrs. S. C. Red, of Texas, Foun-
der of the Woman’s Auxiliary to the American
Medical Association, and its first president, spoke
first of the systematic filing of Auxiliary doings,
and second, of her interest in the history. Mrs.
Red recently compiled a history of early medicine
in Texas, entitled “The Medicine Man in Texas’’;
this is to assist in establishing a loan fund for
medical students in Texas. Mrs. Red’s book has
received very favorable comment.
After luncheon the ladies had their choice of :
(a) Trip to Valley Forge; (b) trip on Delaware
River; (c) visit to Historical Society of Pennsyl-
vania; (d) visit to Print Club.
Following the general meeting of the American
Medical Association with Dr. William Gerry Mor-
gan, of Washington, D. C., retiring president, and
the address of Dr. E. Starr Judd, of Minnesota, in-
coming president, hundreds met again in the ball
room of the Bellevue-Stratford Hotel, at the supper
dance in honor of the Woman’s Auxiliary.
Most of Wednesday morning’s meeting was de-
voted to state reports — the Indiana report written
by Mrs. William S. Tomlin, Indianapolis, was read
by Mrs. F. W. Cregor. One notes a broadening of
the work in the various states as a better under-
standing of possibilities develops. Pennsylvania is
now the banner state with over 1900 members, an
increase of more than 200 in the year.
The Nominating Committee, Mrs. S. C. Red, of
Texas, Chairman, presented the names of Mrs.
Walter Jackson Freeman, Philadelphia, President-
Elect; Mrs. James Blake, Minnesota, First Vice-
President; Mrs. James F. Percy, California, Second
Vice-President; Mrs. J. Ralston Wells, Florida,
Third Vice-President; Mrs. Robert W. Tomlinson,
Delaware, Fourth Vice-President. With their elec-
tion a rising vote of thanks was extended Mrs.
Hunsberger, who presented the gavel and presi-
dent’s pin to her successor, Mrs. Arthur B. Mb-
Glothlan, of St. Joseph, Missouri, elected at the
Detroit session. After felicitations to Mrs. Mc-
Glothlan, the meeting adjourned, and the members
assembled again at the annual Auxiliary luncheon,
with guests and speakers from the American
Medical Association. Mrs. Hunsberger presided,
and Mrs. Joseph J. Meyer, of Pennsylvania, was
toastmistress. Mrs. Meyer introduced Dr. E.
Starr Judd, who expressed his pleasure at attend-
ing such a large gathering of Auxiliary members,
and spoke of the excellent condition of the Aux-
iliary in Minnesota; he then reviewed scenes of
other days, mentioning that in 1847 when the
American Medical Association was organized in
Philadelphia, women were present, and that in
1850 in Cincinnati, they were active in social
gatherings. Dr. Judd spoke of Mrs. Mayo, the
mother of Dr. Will and Dr. Charles Mayo, former
Presidents of the A. M. A., that during the Civil
War when Indian outbreaks in Minnesota kept
many men at home, Dr. Mayo was sent to Man-
kato and New Ulm following a fresh outbreak,
and Mrs. Mayo became the doctor of the com-
munity as soon as her husband left, wounded sol-
diers being brought to the aid station she es-
tablished. He also told of her heroic work during
a diphtheria epidemic. Dr. Judd closed his re-
marks by saying that she was an example for
all, for she took over the activities of her hus-
band and carried on — the real purpose of the Aux-
iliary.
Dr. Walter F. Donaldson, Pittsburgh, spoke
of the Medical Benevolence Fund of the Medical
Society of the State of Pennsylvania, which now
amounts to $87,000; $6000 was contributed by the
Woman's Auxiliary. The fund is to give pecuniary
aid to the members of families of physicians.
Among others introduced was Dr. Joel T. Boone,
jjersonal physician to President Hoover.
In the afternoon there was a trip through his-
toric Philadelphia with tea at Stenton, the home
of James Logan, 1728, friend of William Penn.
This writer elected a visit to the exhibit in the
new Municipal Auditorium, having heard it said
that it was “the best yet’’; it justified such praise.
Then, under the guidance of Mrs. Walter Jack-
son Freeman, a visit was made to the College of
Physicians.
Wednesday night, the Woman’s Auxiliary to the
Medical Society of the State of Pennsylvania en-
tertained at a reception, with a musical program
and buffet supper in the University Museum; the
program was presented with the compliments and
best wishes of Dr. William W. Keen, President of
the American Medical Association 1900-1901.
Thursday morning Mrs. Arthur B. McGlothlan
presided at the general round table conference. In
her Presidential Address, Mrs. McGlothlan out-
lined her plans, saying “There is nothing new to
offer in policy’’, that she would “further develop
the already established policies and give aid to
state auxiliaries.”
The discussions growing out of the subject
“What have I gotten out of this convention?” and
the questions and suggestions from the “Question
Box” (an innovation) were enlightening and enter-
taining. This meeting was followed by the post-
convention Board meeting, Mrs. McGlothlan fur-
ther manifesting her powers of friendly leadership.
In the afternoon there was the choice of a trip
to “Longwood”, estate of Mr. and Mrs. Pierre du
Pont, a visit to Pennsylvania Museum of Art, or
a visit to the College of Physicians.
Thursday night in the ball room of the Benjamin
Franklin Hotel the President’s Ball was held. In
the receiving line were: Dr. and Mrs. E. Starr
Judd and Dr. and Mrs. E. H. Cary.
Friday there was a trip to Atlantic City with
the Atlantic City Auxiliary hostesses at the Clar-
idge, and a tour of Wanamaker’s with luncheon
in the Crystal tea room,.
It was a wonderful convention, one with a very
full program, in which history, culture, science,
procedure and pleasure united to form a perfect
whole.
Respectfully submitted,
Mrs F. W. Cregor.
Hudson County
Reported by Mrs. J. M. Murphy
The following report is a' summary of the ac-
tivities of the Woman’s Auxiliary to the Hudson
County Medical Society during 1929-1930 and
1930-1931 :
Mrs. John Nevin accepted the gavel on which
is written “Presented to the Woman’s Auxiliary
to the Hudson County Medical Society by its first
President, Minnie U. Freile, October 18, 1929”,
and so became second President.
Mrs. Jaffin was appointed Chairman for the
distribution of Hygeia, Miss Hetherington was
appointed Chairman of Program and Publicity,
which committee was later divided into 2, and
as Miss Hetherington expected to be away for
the winter, Mrs. Duckett was appointed Chairman
of Publicity Committee and Mrs. Cosgrove of the
Program Committee.
At the meeting on November 15, we were ad-
dressed by Miss Mabel L. Hannah, of the Field De-
partment of the Welfare Division of the Metropoli-
78S
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
tan Life Insurance Company, on “Adventuring
for Health”. Her topic gave a picture of the
many sided attitudes of the large insurance com-
panies on the extension of the span of life, by
their interest in the public health work.
Following the usual custom of the organiza-
tion, there was no meeting in December; in
January a card pary was held at which time
$160 was added to the funds, and a most enjoyable
afternoon was spent by the members and their
friends.
The February meeting was addressed by Dr.
Levy, Director and Consultant of the State De-
partment of Child Hygiene. He spoke on the
newer trends of public health work and the de-
sirability of the right attitude of doctors toward
these changing trends.
At the March meeting $100 was given to the
following charities: Salvation Army Home and
Hospital, $25; Queen’s Daughter’s Day Nursery,
$25; Hebrew Home for the Aged, $25; and the
Goodwill Day Nursery, $25. At the conclusion of
the business meeting, cards were played.
The April meeting was one of our finest, 3 ex-
cellent speakers addressed us. Mrs. Hunter, State
President, spoke on the aims and duties of the
society; Dr. Margaret Sullivan Heberman gave a
stirring talk on the right of freedom of the
medical profession; our President gave a charm-
ing and dramatic review of Thornton Wilder’s
‘‘Woman of Andros”.
At the final meeting of the season, the Treas-
urer reported $432.84 in the savings account and
a membership of 76; $25 was voted to the Red
Cross, which has a deficit due to the extra calls
made upon that organization. Delegates to the
convention at Atlantic City were appointed: Mrs.
Halligan, Mrs. Klaus and Mrs. Perlberg, with
Mrs. Largay, Mrs. Perkel and Mrs. E. J. Connell
as Alternates.
On October 17, 1930, date of our meetings was
changed from the third to the fourth Friday. In-
vitations were sent to all eligibles to join the
society. Mrs. Freile gave a report of the state
meeting at Atlantic City, at which meeting our
Auxiliary was honored by the election of our
President as President of the Woman’s Auxiliary
to the Medical Society of New Jersey.
On November 21 the membership had increased
to 93. Miss Hetherington was appointed Cor-
responding Secretary to complete Mrs. Binder’s
term, she having resigned due to sickness in the
family. Miss Flack of the Department of Child
Development of Teacher’s College, Columbia,
spoke on “Adult, Child Relationship”.
The January Card Party was again a success:
$134.05 having been cleared, the balance now is
$993.78. The following charities were chosen to
be assisted: St. Anne’s Lome for the Aged, He-
brew Orphans’ Home, Red Cross Visiting Nurse
Service, and the Helping Hand Society of North
Hudson; $25 being given to each.
Mrs. Taneyhill spoke at the February meeting
on Mental Hygiene, giving a lively and instruc-
tive address; at the March meeting, we had Mr.
Coleman, Secretary of the Jersey City Health
Council, who spoke on “New Developments in the
Field of Tuberculosis”. Delegates to the state con-
vention were appointed: Mrs. Klaus, Mrs. Duckett,
and Mrs. Daly, with Mrs. Barishaw, Miss Hether-
ington and Mrs. Nicholson as Alternates. At the
April meeting the membership was 110.
Members of the society attended the semi-
annual state luncheon at Trenton, January 12,
1931, and the one in Newark in 1930.
Members and their guests enjoyed the Play
Day at the Areola Golf Club, May 27, 1930, and
a similar event planned for May 26, 1931.
At the May meeting $25 was voted to the Red
Cross. The nominating committee submitted its
report as follows: President, Mrs. George M. Cul-
ver; First Vice-President, Mrs. Henry Klaus; Sec-
ond Vice-President, Mirs. Warren J. Duckett;
Recording Secretary, Mrs. Emmett J. Connell;
Corresponding Secretary, Mrs. Louis L. Perkel.
These officers were elected; the treasurer, Mrs.
Harry Perlberg, continued in her office.
County Society Reports
ATLANTIC COUNTY
Atlantic City Hospital Staff
Joseph H. Marcus, M.D., Secretary
The regular monthly meeting of the Atlantic
City Hospital Staff was held August 28, in the
Auditorium, the meeting being called to order by
President Milton S. Ireland. The minutes of the
previous meeting were accepted as read.
The scientific program was presented by Dr.
Homer I. Silvers. Report of Service, 1931: This
service has been a busy one, embracing varied
types of illness, calling for care and close attention
on the part of the intern on duty. It has been a
pleasant one, and a profitable one, made so by the
cooperation of those whose duties brought them in
contact with this service. Our appreciation is ex-
pressed to the medical department, whose help and
assistance have been invaluable and always cheer-
fully given; and to the operating room unit,
whose patience I sometimes tried. It is the for-
tune of this service to take on new interns at a
very busy season, and expect the new men to
promptly take up the work and carry it on suc-
cessfully. This year I am much indebted to
Dr. Harris on the men’s side, and to Dr. Tullock
on the women’s side, for assistance that has been
most satisfactory; being efficient and well execut-
ed. Dr. Subin gave his time and skill in the ad-
ministrating of spinal anesthesia, and my regret
is only that we did not use this form of anes-
thesia more often.
The service has been active, but at times it
seemed to slow up, but as the better weather of
summer approached, the annual crop of injuries,
many of them terribly mutilating, made their ap-
pearance.
There were 2 70 patients admitted to the wards,
and of this number there were 49 patients ad-
mitted with head injuries; 4 deaths occurred in
this group. This year we have adhered to the
conservative mode of treating cerebral injuries,
and if we judge by the death rate, it was em-
ininently satisfactory, but judging by that method
is to my mind hardly a fair anaylsis, for that
group of 49 takes in all grades of injuries to
brain tissue, many of whom had only short
periods of unconsciousness or other symptoms
of brain contusion.
There were no operations for skull fracture or
its complications. Reliance was placed entirely
upon early spinal drainage, which was repeated
often, and at times at short intervals. This method
served us well, and while it entailed more spinal
puncture, which under some circumstances was
trying and difficult, it has justified itself in this
service. However, the longer it is used, the
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
789
clearer will become our understanding of the
work, and the certainty of the procedure be
proved, or disproved.
Broken backs form a very distressing form of
injury. The hopelessness of the lesion that has
caused a complete paralysis only being matched
by the individual, who is often keenly hopeful
and cheerful.
We had 3 men admitted with fractured spines:
2 from diving in shallow water, and 1 as the re-
sult of an automobile accident; 2 were fractures
in the upper dorsal region, and 1 in the lower
cervical region; 1 was transferred to the private
side, but all 3 died.
This year there were not a great many badly
infected bone cases, or long-standing osteomye-
litic conditions that taxed the patience of all con-
cerned in their care. Two reasons for this are
apparent: first, there were not so many badly
compounded fractures admitted; secondly, there
was a distinct attempt to see all fractures ad-
mitted, as early as possible, and for this I have
to thank Dr. Irvin for his willingness to make
all fracture cases an emergency, and to see them
immediately. I am sure for this reason many
compound fractures were converted into simple
ones, and a destructive infection avoided that
might have been disastrous to the patient.
Avertin was used as a routine anesthesia, ex-
cept in those admitted for emergency opera-
tions, or those too ill to move to ascertain their
weight. From the patients’ point of view it is
an ideal anesthetic; their going to sleep in their
bed, not being aware of their removal from bed;
with no shock or stress to the patient, as is so
frequently the way we commonly handle our
operative cases. With the patient brought to
the operating room, placed upon the table, hands
strapped down; the rattle of instruments; the
hiss of the sterilizers; and watching the assist-
ants work around, looking like members of the
Kuklux, make it a wonder to me that people do
not rebel. In contradistinction to this, under
avertin your patient is placed upon the table,
sleeping quietly, naturally, and is not disturbed
by the work going on around him.
Avertin should not be looked upon as a com-
plete anesthesia, but rather as a basal anesthetic
to which must be added some other form, usually
inhalation to complete the anesthesia. The pa-
tient sleeps for a considerable period after being
returned to bed, and then usually awakens very
much as one would from a long sleep, with no
recollection of having left his bed.
Dr. Silvers emphasized the importance of pre-
serving accurate and well taken histories of each
individual who enters the hospital. Histories are
taken for 2 main reasons: first to get a logical,
concise sequence of events, secondly, with the
progress noted, to form an accurate, lasting pic-
ture of the patient up to the time of discharge
from the hospital. The quality and usefulness
of these records would seem to rest solely with
the members of the staff and the attending phy-
sicians, who at all times pay attention to the ef-
forts exerted by the residents. He also urged
more conscientious efforts in obtaining more
necropsies and a more constant and persistent
contact with the outpatient department.
Dr. John S. Irvin, Associate, presented statis-
tics of the mortalities with a brief portrayal of
each case.
Dr. Donald C. Tullock, resident physician, pre-
sented “The Stimulation of Wound Healing”.
From the very beginning of medicine, attempts
have been made to help nature speed up her
efforts in the healing of wounds. Various chemi-
cals have been used, different forms of bandages
and dressings have been applied, and the effects
of temperature have been investigated. In fact,
apparently optimum conditions have been reached
in many cases only to find that the sluggish
tissues fail to respond in an adequate manner.
Many chemicals have been advocated from time
to time with claims which have been in some
cases absurd. In others the chemicals have
proved their value in selected cases only. There
seems to be no substance wvhich actively stimu-
lates wound healing in cases selected at random.
Many different procedures have been tried, such
as vitamins, dyes, irradiation, and irradiated
pastes and ointments, attempts at changing the
acid base equilibrium of the body, divers other
measures from the sublime to the ridiculous.
My purpose is not to review the entire subject
but to briefly review some of the literature on
one of the newer chemicals which appears to
have merits not possessed by some of the older
substances.
Personally, I have no claims for this chemical,
having had little or no practical experience with
it. It may seem peculiar then, that I pick this
particular topic. The reason is twofold. First,
it cannot be denied that slowly healing wounds
increase the number of hospital days, hence they
are of economic importance. The second reason
is that the application of this chemical is based
on sound and logical reasoning which at least
removes it from the trial and error class in which
so many of the wound stimulants fall.
The original article was published by Dr. L. P.
Reiman, of Philadelphia, in May 1930. Realizing
the inadequacy of wound stimulants, he, with
some co-workers, decided that there must be a
difference in chemical composition between nor-
mal ills and the devitalized and sluggish tissues
of wounds that fail to heal. Chemical analysis
revealed the fact that there was a quantitative
difference in the sulphur on this radicle. This
applied only to the sulphur organic combination.
He immediately set about to find ways and means
to supply sulphur to the deficient cells. Many
substances containing sulphur or inorganic com-
pounds were tried without results. Next came
a combination of the sulphur radicle and glu-
cose. In this case the glucose merely acted as
a bacterial medium and the cure was worse than
the disease. He next decided to continue the
sulphur with some form of antiseptic. To this
end various chemicals were compounded until
he finally found one which he believed filled the
specifications. This was cresol with the sulphur
radicle inserted in the para position of the ben-
zene rings — chemically, para-thio-cresol. This
substance, then, in theory at least, was ideal. The
sulphur would supply the deficient chemical while
the cresol would inhibit bacterial growth. The
first experimental work was done on animals with
results which corroborated exceedingly well the
original theory. Naturally, the next step was
to try this new substance on humans. Several
cases of old wounds were used for the most part
with good results. There is no need to cite all
of the cases treated. I am, however, including a
typical case so treated verbatim:
Mrs. C., aged 30 yr„ was injured 21 yr. ago
by a heavy weight falling on the outer side of the
left foot. A bruise resulted, and from the his-
tory large vessels were probably severely in-
jured. The part remained tender and sensitive.
An ulcer appeared 14 yr. ago which healed sev-
eral times after rest, skin grafting and other
790
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
procedures, but only for short periods of time.
On examination in May 1930, an ulcer, several
years old, 5x6 cm. and .05 cm. deep, presented
a fairly clean dull brown red base and hardened,
slightly inverted edges. The skin surrounding
was pigmented light brown, slightly edematous,
poorly vascular. Treatment with 1:10,000 solu-
tion of this cresol resulted in complete healing in
3 weeks. The epithelium covering the old de-
nuded area was thin and delicate. The patient
was anxious lest a slight trauma again break the
surface. One quarter of 1% thio-cresol in lana-
lin was rubbed in 3 times a week. In 3 weeks
the new skin was thicker to the touch than the
normal skin of the foot, though feeling movable
over the underlying fascia. Its color and reaction
to momentary pressure showed good vasculariza-
tion.
This case, and similarly others seem to show
that para-thio-cresol does stimulate all prolifer-
ation to a marked degree. This seems to apply
also to epithelium. Further experiments are
•being carried on by the same workers and their
results are to be published in due time.
The method of application is far from compli-
cated. A 1:10,000 solution is made up as follows:
The chemical is just dissolved in a small amount
of 95% alcohol because of its limited solubility
in water. For a liter of solution — 1 gm. of thio-
cresol is dissolved in about 40-50 c.c. of alcohol.
This is then made up to a liter with water (pref-
erably distilled). This solution is used as a con-
tinuous wet dressing for 48 hr. at the end of
which time it is discontinued for the next 24-
48 hr. The reason for the discontinuance is that
the newly formed cells are to be allowed a chance
to increase to a size approaching normal. After
this interval the wet dressing is again instituted.
Once the then delicate epithelium has grown over
the wound it may be stimulated to increased ac-
tivity by the use of a lanalin ointment of % %
para-thio-cresol. Later work seems to favor a
less concentrated ointment such as .1%, for
reasons to be mentioned later.
There are some disadvantages to the use of
this preparation. The solution should be freshly
prepared, but due to the dose of preparation this
is a practically negligible factor.
Its greatest disadvantage lies in its odor, which
is that characteristic of any organic sulphur com-
pound. While this is disagreeable it may be
obviated somewhat by the use of aromatics. It is
claimed that the patient becomes accustomed to
the odor to some extent. The third disadvantage
is that some patients appear to be susceptible to
•the solution — developing blebs and pustules about
the wound. This is true only of a small percent-
age of cases. In such an event weaker solutions
can be used or treatment can be readily discon-
tinued with no harm done.
This work has been carried on in a recognized
institute by competent workers. The theory of
its application is sound. For these reasons, at
least, the chemical merits a trial to this end. The
preparation was ordered by the hospital phar-
macy and arrived about the time the services
changed. For this reason I can offer no clinical
data as to its usefulness.
I offer this brief review of the subject merely
for what it may be worth. Possibly it may turn
out to be just another so-called stimulant to
wound healing. On the other hand the chemical
may actually be of value. However, I do feel
that due to the sound theoretic consideation in-
volved, it is worth at least passing mention, if
not complete clinical investigation.
Dr. William G. Harris gave a report on “Frac-
tures of Cervical Spine”. Due to the great in-
crease in the number of automobile accidents, the
incidence of fractures of the spine has increased
and for this same reason at the same time there
has been a proportionate increase among women.
While this statement may hold true as a general
rule, yet, in 3 cases of fractures of the cervical
spine seen in the men’s surgical ward during July,
only 1 was due to an automobile accident, while
the other 2 were due to diving in shallow water.
The most frequent case of fracture of the
cervical spine is indirect evidence due to a fail
upon the head, feet or buttocks, the force of the
fall causing a hyperflexion or hyperextension of
the spine.
As is well realized, the danger of spinal frac-
tures is due to cord injury which varies greatly
in each individual case, the said injury being in
no way entirely dependent upon bone damage,
and that the evidence of cord injury may change
hour by hour.
The 3 cases seen during July all showed rather
typical signs of fracture with definite history of
injury. Two of these showed fractures of the
cervical vertebra with corresponding cord dam-
age while in the other no fracture was demon-
strated by x-rays, although, clinically, there was
injury to cervical or upper thoracic cord.
Clinically, spine fractures are diagnosed by
history of injury, paralysis of muscles, loss of
sensation, exaggerated or loss of reflexes. It is
said that all casgs of spine fractures with cord
injury show some abdominal symptoms as dis-
tention and constipation. Bladder symptoms also
vary in their intensity but it is said that they
are seen less often than distention of the abdomen.
Priapism is another important finding which
should not be overooked and, when present, de-
notes severe cord damage, suggesting a serious
outcome.
The cases which we saw all showed paralysis
of muscles, in 1 only the right side of the body
being involved while the other 2 showed com-
plete paralysis below the upper extremities with
weakness of the upper extremities and a loss of
sensation below the second rib and along the
ulnar side of the arms and the forearms. All
showed early abdominal distention and inability
to void. Priapism was noted only in 1 case
and then only at time of admittance.
Where there is complete paralysis, it is doubt-
ful whether the patient is benefited by treatment
at all. In all cases 2 methods of attempting re-
ductions are available: one by gradual exten-
sion, and the other by attempt to reduce the dis-
location under anesthesia; the latter being by far
the most dangerous.
In 2 of our cases, we used gradual extension
by means of the jury mask, and, so far as results
were obtained in preventing further damage to
the cord,_ the results were as good as could be
wished for, although 1 of these individuals lived
only 4 hr. after his injury. On the other indi-
vidual in whom no bone changes were demon-
strated, immobilization was effected on an air
mattress between sandbags. In all patients it
was necessary that they be catheterized and ab-
dominal distention relieved by enemas. We also
attempted in these cases, as in head injuries, to
prevent edema of injured cord by the restriction
of the intake of fluids.
Operative treatment of these fractures has fal-
len into disrepute, except in those cases where
spicules of bone are pressing upon the cord or
where there are signs and symptoms of cord
Oct., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
791
pressure either due to hemorrhage or edema
about the cord without evidence of cord injury.
The cause of death in these patients is often
puzzling. Injury to the vital centers in the
medulla will cause instantaneous death. One of
our patients appeared to be progressing nicely
although he had developed an aptitis and sud-
denly, or, rather, within 12 hr. was moribund.
The 3 patients seen all showed evidence of se-
vere cord damage and none recovered. Yet, with
a larger number of patients, and with the treat-
ment we used, we would get recoveries, for the
mortality of all spine fractures is quoted as
above 50%.
BERGEN COUNTY
Charles H. Littwin, M.D., Reporter
There was a special meeting of the Bergen
County Medical Society on August 12, 1931, at the
Bergen County Isolation Hospital for the purpose
of discussing the present status of poliomyelitis.
Dr. Morrow presided and there were about 50 men
present. The speaker of the evening was Dr.
Scheffer, Assistant Deputy Superintendent of the
Willard Parker Hospital, New York City.
The following is an abstract of his address:
The present status of poliomyelitis. The present
outbreak of poliomyelitis is the second largest in
history; the severest outbreak being that of 1916,
when there were in New York City alone 9000
cases, with a mortality of 26.6%. In the present
outbreak, the mortality is only 12.6%, which is
considered quite low.
This dreaded disease is still shrouded in much
mystery. Research work is constantly being done,
especially during the epidemic, by men devoting
their entire time to the study of poliomyelitis.
Etiology of poliomyelitis. Nothing very definite
is known about the causative factor of poliomye-
litis. One should always remember the carrier.
Healthy carriers are the most prolific. The fly is
commonly suspected as a carrier, and it is possible
that it carries the polio germ. Infected milk is
also suspected but these cannot be proved.
History of poliomyelitis. Poliomyelitis is a rela-
tively new disease in the history of medicine. In
1840, Heine, of Germany, drew a good description
of the disease. However, his observations were
limited mainly to the paralytic stage, and his chief
contribution was in separating the paralytic from
the pre-paralytic stage.
In 1890, Meden published his study of the disease
in Sweden, and described the outbreak of polio-
myelitis prior to 1890.
By 1909 there was a more thorough research,
and also an experimental approach to the disease.
It, was possible to get an idea of the virus and
its character, and methods were discovered to
study the disease experimentally. Thus, Gand-
steiner and Poff discovered that the disease was
transmissible to monkeys which are an excellent
experimental medium.
Flexner and Lewis made further studies with re-
spect to immunity in animals recovered from the
disease. Also it was found that individuals who have
had the disease have in their blood substances, such
as antibodies, which neutralize the virus of polio-
myelitis. An emulsion of virus and serum intro-
duced cerebrally in a monkey fails to produce the
disease. The virus alone does produce the dis-
ease. Most adults contain in their blood anti-
virus which renders them relatively immune.
Attempts to immunize sheep and horses against
the virus to produce anti-virus have been made.
In 1917 Banzalip and Neustader succeeded in im-
munizing the horse against poliomyelitis and in
producing in the horse's blood anti-virus material.
This horse serum is now used experimentally in
New York City but is not available for general
use and its value has not yet been proved.
Polio-cord virus from monkeys has been suc-
cessfully used by Pettitt and Levatidi in the treat-
ment of poliomyelitis. Weyer, Banzalip and Park
at the Willard Parker Hospital have produced a
very potent anti-virus which is a most valuable
clinical adjunct in the treatment of the disease.
Clinical aspects of poliomyelitis. During previous
epidemics much confusion existed as to the charac-
ter of the symptoms and their proper classification,
as manifested in the various stages of the disease.
This confusion and uncertainty, which still ex-
ist to some degree at present, arose out of the
fact that, at the beginning, the symptoms are so
slight and generalized that almost any of a great
number of other diseases display the same phe-
nomena. Thus we have an onset which lasts
from 1 or 2 days to a week. It is characterized by
general malaise, headache, nausea or vomiting,
gastro-intestinal upset, perhaps a slight fever,
pain in the back or limbs, and moderate rise of
pulse. At this stage the disease may suddenly
become arrested. For this reason some authorities
have called it the abortive type of poliomyelitis.
The spinal fluid in these cases is practically nega-
tive, showing no globulin and a few cells, not ex-
ceeding the high normal of 7 or 8. The patients
improve rapidly in a day or two.
In other cases, the symptoms described above
become more severe, and, in addition, there usually
is present pain and rigidity of the neck, a little
higher fever, and more rapid pulse. The Kernig
sign is positive, and there are evidences of a
meningeal character, when the patient in a sitting
posture makes any forward movement from the
hips. The head may be moved on the neck, but
not the neck on the shoulders. These symptoms
are invariably present, and they are accompanied
by an increase of tenderness in the reflexes in all
extremities. Thus, we have the pre-paralytic
stage. The spinal fluid here will be found to con-
tain a cell count of 50 to 200, polymorphonuclear
cells predominating; globulin is also present to a
more or less degree.
If the case progresses, there will be a diminu-
tion of the reflexes with general hyperesthesia;
the child is fretful and irritable, temperature is
102°, pulse is rapid, there will be general pros-
tration, and finally the reflexes will disappear, and
paralysis will ensue. This paralysis may involve
1 or 2 muscles, or groups of muscles, thus affect-
ing entire limbs. Thus, the paraylitic stage has
ushered in, and the spinal fluid here has a ground-
glass appearance, contains globulin and a cell
count of from 200 to 600 cells. The onset from
the pre-paralytic to the paralytic stage may be
rapid: often in only a few hours there may be ex-
tensive paralysis of whole groups of muscles.
Usually, however, it is 4 to 6 days. The incuba-
tion period lasts from 4 to 9 days.
The treatment of poliomyelitis. The treatment
of acute poliomyelitis at present is almost entirely
by means of convalescent patients’ serum. The
value of this treatment is difficult to estimate, be-
cause there is no sharp line of demarcation clini-
cally between the different stages of the disease.
However, from extensive observations, it has been
found that the serum will be most effective in the
pre-paralytic stage. Once paralysis has set in, it
has been found that the serum is of little value.
Intramuscular injections, usually in the buttocks,
is the method of choice. Formerly intraspinal and
intranervous injections were given, but these cases
were attended by severe anaphylactic shock, with-
792
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1931
out displaying any superior results. The dosage
of the intramuscular injections of serum varies ac-
cording to the severity of the case, generally 30
c.c. for infants, up to 80 or 100 c.c. for adults.
Aycock and Luther made very accurate observa-
tions on the therapeutic value of treatment with
serum. Of 106 cases, 65% developed paralysis;
35% escaped. This is similar to the observations
made by Ivan Whitman in 1905, who studied the
outbreak in Sweden ; 40 % to 60 of prodromal cases
failed to develop paralysis. In those pre-paraly-
tic cases where the treatment by serum does not
check the oncoming of paralysis, it has been found,
nevertheless, that the extent and degree of paraly-
sis were lessened. This is proved by observations
in other institutions where control cases, that is
untreated cases, show greater involvement and se-
verity of paralysis.
As to treatment by horse serum, it has been
shown that its value is doubtful. In addition, the
risk of its administration is too great, especially
if given intravenously or intraspinally, as it gives
rise to excessively severe reactions (anaphylaxis).
In the bulbar types of the paralytic stage, there
is a great degree of vascular engorgement and hy-
peremia of the medulla. This produces edema and
consequent great pressure upon the structures of
the brain. These cases are not amenable to serum
treatment. But it has been found that intra-
spinal injections of ephedrin in 60 mg. doses at 8
to 12 hour intervals will tend to relieve the pres-
sure by diminishing the edema. But here again,
we cannot be too optimistic because many of these
cases, especially the severe ones, will not respond
to ephedrin.
The Drinker respirator is in use at the larger
institutions, such as the Willard Parker, in inter-
costal and phrenic types of poliomyelitis. But it
has only limited value, and the bulbar type is not
benefited. In general, we may say that the treat-
ment of paralytic cases, even at an early stage of
the paralysis, is futile because extensive damage
has already been done to the central nervous sys-
tem by the time paralysis makes its first appear-
ance.
Paralytic and post-paralytic cases are treated
simply by orthopedic measures. Orthopedic treat-
ment, however, is not instituted until 6 or 8 or
more weeks after the beginning of the onset.
Summary
(1) Acute anterior poliomyelitis is a disease
that is still very baffling, since nothing very defi-
nite is known, especially as regards the etiology
and the treatment.
(2) Most normal human adults are immune;
children are not immune.
(3) The treatment is almost exclusively limited
to convalescent patients’ serum. Horse serum has
proved to be unsatisfactory and unsafe, as it gives
rise to severe reactions. Post-paralytic cases are
treated by orthopedic means 6-8 weeks or more
after the onset.
(4) The serum is of value only in the pre-para-
lytic cases. Once paralysis has set in, serum is
of little or no value.
(5) Those who have had the disease are im-
mune to any further attack, as they have develop-
ed in their blood certain substances, called anti-
bodies, which neutralize the virus of poliomyelitis.
BURLINGTON COUNTY
Roscius I. Downs, M.D., Reporter
The regular meeting of the Burlington County
■ Medical Society was held in the Community
House, Moorestown, New Jersey, on September 9.
President Kuder called the meeting to order at
1.30 p. m., with 26 members and guests present.
The guests included, Drs. Henry H. Lott, of Phil-
adelphia, and Henry B. Diverty, of Woodbury.
The minutes of the previous meeting were read
and approved.
Dr. Newcomb invited the society to hold a
clinic for its members once a month at “Fair-
view’’, the tuberculosis sanatorium. This invi-
tation was accepted and the second Friday of
each month selected.
Dr. Kuder outlined his views on “Public Re-
lations” and “Medical Publicity in Burlington
County”. He spoke as follows: The consensus
of opinion is that some sort of publicity should
be applied, by which the public will be made to
understand the nature, purpose and results of
efforts made by scientific medicine in the pre-
vention, control and cure of disease.
Several life insurance companies, one in par-
ticular, actuated presumably by broad-visioned
business motives, are rendering services of sig-
nal value along the lines of preventive medcine.
The extent of popular medical education, though
it has only begun to grow into what it is bound
to become, is steadily broadening.
People like to be told about their health and
like to know how to keep healthy, unwilling as
they may be to observe the rules of health and
hygiene laid down for them.
It is unfortunate that we, as medical men, who
are the logical preceptors in such matters, teach
the public so little about the fundamentals of our
science. Few of us have that particular gift of
separating simple essentials from intricate sur-
roundings. So far as medicine is concerned,
many of us have forgotten our mother tongue
and speak only of the precise but formidable
dialect of our professional tribe. Even when we
are able to overcome these handicaps, some doc-
tors under that wet blanket of ethics tear hair
and gnash teeth at suggested publicity on the
part of medical societies claiming it will result
in personal advertising by individual physicians.
The public should receive medical information
from physicians rather than from charlatans or
quacks.
A Committee of Public Relations has been
formed. Its present purpose is to plan and pre-
sent free public lectures by members of the
county society to the public. The campaign will
depend upon willingness of the members to back
this movement, and the creation of proper local
sentiment to receive these lectures. Different mem-
bers of the society will prepare lectures on the
several common medical subjects. There will be
2 speeches on each subject. The date, hour and
subject will be arranged under the auspices of
the Burlington County Medical Society with the
name of the speaker withheld. The committee is
composed of the County .Society President and
Secretary, Drs. Reisinger, Emlen Stokes, Hunter,
Remer and Newcomb.
The scientific program followed; “Some Prac-
tical Hints for the General Practitioner to Im-
prove His Treatment of Eye and Ear Patients”,
by Dr. Daniel F. Remer, of Mount Holly, and
“Acute Sinus Infections Dealt With By The Gen-
eral Practitioner”, by Dr. Henry H. Lott, of Phila-
delphia.
Dr. Remer's paper was so practical and apropos
for the family doctor that it will be forwarded to
the Journal for publication.
Dr. Lott said that acute sinus infections need
not go to a specialist. Fifty per cent of the
patients will be aborted by shrinking the mucous
membrane of the nose, applying local ice for the
Oct, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
793
first 24 hr. and opening- the bowels. In 5-7 days,
75% of the cases will clear up. The following H.
C. solution was given to shrink the nasal mucous
membrane and to open nasal drainage; cocain gr.
2, menthal gr. 2, camphor gr. 2, oil of rose m. 2,
liquid alboline oz. 1.
In acute antrum cases, posterior drainage 3
times a day is a benefit. This position is present
when shoes are placed under a bed. In 5-7 days,
if no relief is present use vaccine. Dr. Lott uses
Sherman's number 36 with wonderful results.
It is probably due to the Friedlander bacillus in
the vaccine. Twenty-four to forty-eight hours
after the first dose, one half of the cases will
open up.
To recapitulate: Do not send every sinus case
to a specialist. Try first purgation astringents to
nasal mucous membrane, posterior drainage, and
vaccines.
GLOUCESTER COUNTY
Henry B. Diverty, M.D., Reporter
The annual social session of the Gloucester
County Medical Society was held September 17,
at the Hotel pitman. It proved to be a very en-
joyable affair.
A dinner was served to the physicians, their
wives and guests. Music was provided by Leslie
Sellen and 2 fellow musicians, while the Adelphia
Quartette, of Philadelphia, offered a number of
selections which were very much appreciated.
Dr. Wilmer Krusen, of Philadelphia, the guest
speaker, gave a splendid talk. Later dancing and
cards were enjoyed.
Those present were: Dr. and Mrs. Duncan
Campbell, Dr. and Mrs. J. Harris Underwood,
their daughter, Dorothy, and her guest; Dr. and
Mrs. E. E. Downs, Mrs. Paul Pegau and Dr. and
Mrs. H. B. Diverty, all of Woodbury; Dr. and
Mrs. Chester I. Ulmer, of Gibbstown; Dr. and
Mrs. S. A. Ashcraft, of Mullica Hill; Dr. and Mrs.
C. F. Fisler, of Clayton; Dr. and Mrs. H. Wilson
Stout, of Wenonah; Dr. and Mrs. I. W. Knight,
of Pitman; Dr. and Mrs. R. I<. Hollinshed, of
Westville.
The guests were: Dr. and Mrs. Don Weems, of
Wenonah; Dr. and Mrs. Summerill, of Pennsgrove;
Dr. Emma Richardson, of Camden; Mrs. George
E. Reading, widow of the late Dr. Reading, of
Woodbury; Dr. and Mrs. Church, of Salem; Dr.
and Mrs. Miller, of Millville; Dr. and Mrs. Fuller
Sherman, Dr. and Mrs. Oram Kline and Dr. and
Mrs. Ralph Moore, all of Woodbury.
MORRIS COUNTY
Marcus A. Curry, M.D., Reporter
The annual meeting of the Morris County Medi-
cal Society was held in the recreation hall of the
Cafeteria Building at the State Hospital at Grey-
stone Park, on the evening of September 30.
President Sutphen was privileged to preside over
an exceptionally well attended meeting of approxi-
mately 70 members and guests; among the latter
being President Hagerty and Secretary Morrison
of the State Society; Councilor Beling and Dr.
Pinneo, of Newark; Clinical Director T. B. Neil
and Staff Members, David Gardner, Ernest Hirr-
schoff and Richard L. Eltinge, of the United States
Veteran’s Hospital at Lyons, New Jersey; also Dr.
Henry O. Carhart, of Blairstown, New Jersey.
The scientific chapter of the meeting was given
the right of way and the speaker of the evening,
Dr. George Draper, of New York City, Associate
Professor of Medicine at College of Physicians and
Surgeons, and Attending at the Presbyterian Hos-
pital, was introduced by the President to tell about
“Poliomyelitis’’.
Dr. Draper prefaced a very interesting discussion
of this present day problem by saying that he did
not know whether the President was correct in
saying that he would “tell about poliomyelitis”;
that it is a very perplexing malady that has been
under study in this country for a good many years,
both clinically and laborat orally ; that a striking
feature of the problem is that the things being said
about it now were said back in 1916; that this sit-
uation is very discouraging but there are 2 or 3
points that seem to be worth-while bringing up to
be discussed to bring out some points of view that
might add to our knowledge; that, of course, one
thing is getting clearer, and that is poliomyelitis
is not essentially a paralytic disease; the fact is
that the cases that are paralyzed are so tragic
and gripping in their appearance that they have
taken a grip on the physicians and this has re-
tarded progress in a knowledge of the disease, be-
cause we have dwelt on that; so if we could think
of it as a general systemic disease we might be
able to get a new point of view; and stressing the
point that so long as the virus remains in the
blood stream nothing happens, but when it enters
the cerebral spinal tissue, then we are running
into danger; that he did not think anyone knew
the answer and there never was such an opportun-
ity for clinical observation as this disease pre-
sents; citing a very low percentage that developed
muscular weakness and that more than half re-
cover complete power within a reasonable period
of time; that this gives quite a different feeling
about paralytic cases; that, the small percentage
who develop muscular weakness brings up the
significance of these paralyzed individuals and ask-
ing why it is that 10% or 15% or perhaps 17%
develop paralysis while the others do not; also
explaining a very interesting study he has been
making recently of the type of child that appar-
ently is susceptible to the disease; that the dis-
ease seems to attack the large, well-nourished,
overgrown and oversized children who generally
run large for their age; also citing several children
in the same family where one will have the dis-
ease and^ the others will not, and other family
groups where 3 or 4 will have the same early
symptoms and only one will develop muscular
weakness, and this one will be of a different type
from the other siblings; pointing out the difficulty
of a quarantine as the milder cases are running at
large and also pointing to the more probable lower
percentage of paralysis if it were possible to figure
on the basis of the known cases combined with
those that pass unnoticed ; - that the disease re-
quires everybody’s attention to work out the prob-
lem; and stressing the importance of immediate
diagnosis.
Dr. Draper’s discussion was illustrated by lan-
tern slides of patients and charts, and evoked
rather extensive discussion which was taken part
in by Drs. Hagerty, McMurtrie, Haven, Krauss,
Young, Rubin, Larson, Emory, Morrison and oth-
ers.
At the conclusion, Dr. Draper was given a ris-
ing vote of thanks.
The business chapter of the meeting was taken
up and it included the reading and approval of
the proceedings of the June meeting and the re-
port of the activities of the Executive Committee.
The Treasurer’s report gave the balance on hand
at the beginning of the year, the receipts and dis-
bursements during the year, and showed a balance
of $1219.32; of the membership of 83 there was only
one delinquent. With only about $400 left after
7!M
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Oct., 1 931
payment of the dues to the State Society, the ques-
tion was raised about continuing’ the library which
is maintained at the Morristown Public Library.
This was discussed and Dr. Larson stressed the
value of this as years roll on, and an action was
taken that the current library now being accu-
mulated be continued for the next 10 years.
Dr. Charles Dykeman, of Morristown, and Dr.
Harold S. Hatch, Superintendent of the Morris
County Tuberculosis Sanitarium, were proposed for
membership and referred to the Credentials Com-
mittee. Dr. Attilo Galasso, of Morris Plains, who
was proposed at the June meeting’, was unani-
mously elected. Officers for the new year as rec-
ommended by the Nominating Committee were
unanimously elected as follows:
President, Fletcher I. Krauss; Vice-President,
Frank N. Pinckney; Treasurer, George J. Young;
Secretary, Albert J. Ward; Reporter, Marcus A
Curry; Historian, Henry W. Kice. For councilor
members of the Executive Committee: Drs. Sut-
phen, Frost and McElroy; for members of the
House of Delegates of the State Society for 3
years, Drs. Teskey and Teller; Alternates: Drs.
Gilbertson and Truax; for member to represent
the society on the Nominating Committee of the
State Society, Dr. Costello.
After the meeting, by invitation of Superinten-
dent Curry of the State Hospital, the members and
guests enjoyed refreshments in the cafeteria.
PASSAIC COUNTY
Wayne W. Hall, M.D., Secretary
The regular meeting of the Passaic County
Medical Society was held at the Health Center,
Paterson, September 4, with Dr. Carlisle presid-
ing. There were 35 members present. The min-
utes of the May meeting were approved as read.
Dr. David Polowe, of Paterson, presented a
case of Banti’s Disease, treated by splenectomy.
Dr. Murray H. Bass, Associate Pediatrician, Mt.
Sinai Hospital, New York City, presented a pa-
per on “Serum Therapy”. It covered practical
considerations of its value and its dangers in
treatment of diseases of children.
This paper stimulated considerable discussion,
due to the prevalence of the infantile paralysis
epidemic. The use of convalescent serum was
described in detail. The discussion was partici-
pated in by Drs. Donald Low, S. A. Levinsohn.
L. G. Shapiro, J. Piller, and G. M. Levitas.
Dr. Carlisle appointed a Nominating Commit-
tee for the election of officers for the coming
year. This committee consists of Drs. J. P. Mor-
rill, Paterson, Chairman; O. R. Hagen, Paterson;
and J. N. Ryan, Passaic.
Obituaries
GARRISON, Biddle H„ M.D., Chief of Staff of
the Ann May Memorial Hospital at Spring Lake
since its inception, and a leading North Jersey
surgeon, died August 29, 1931, at his Vista Place
home on the Shrewsbury River, Red Bank, of
hardening of the arteries, after a lingering illness.
He was 54 years old.
Dr. Garrison had undergone treatment at the
Union Memorial Hospital at Baltimore, and had
spent part of the winter in Nassau, Florida and
North Carolina. He had been home for the past
9 weeks, and had been in a serious condition.
Dr. Garrison was a Fellow of the American
College of Surgeons, and had been active in the
practice of medicine since 1900, a period of 31
years, first settling at Long Branch after serving
as an intern at the National Homeopathic Hos-
pital at Washington, D. C. He was born at
Elmer, Salem County, February 17, 1877, attend-
ed the Elmer High School and was graduated
from the New Jersey Academy in 1894 and the
Hahnemann Medical College, Philadelphia, May
12, 1898.
In 1901, after practicing in Long Branch for
15 months, Dr. Garrison moved to Red Bank,
acquiring the practice of the late Dr. John Calvin
Rush, who moved to Eatontown. He had since
been an active practitioner, being Chief of Staff
of the Spring Lake Hospital since 1906. Dr.
Garrison was the senior surgeon at the Ann May
Hospital and for many years a member of the
Monmouth Memorial Hospital Staff at Long
Branch, and at the time of his death was a con-
sulting surgeon. He was a visiting surgeon of
the Riverview Hospital, Red Bank; consulting
surgeon at the Monmouth County Tubercular
Hospital at Allenwood; a member of the Ameri-
can Institute of Homeopathy, American Medical
Association, New Jersey Homeopathic Medical So-
ciety, Medical Society of New Jersey, a past presi-
dent of the Monmouth County Medical Society
and a past president of the old Monmouth County
Homeopathic Society; New York Academy of
Pathological Science and New York Surgical and
Gynecological Society, and New Jersey Hospital
Association.
TAGGART, Thomas Dartnell, of 25 South In-
diana Avenue, Atlantic City, died in St. Louis,
Missouri, on September 23, 1931, as the result of
an operation.
Dr. Taggart, who had been connected with the
Atlantic City Hospital for 25 years, being chief
of the surgical staff when death came, was taken
ill in March. Pneumonia and a heart condition
were successfully resisted, and he left the hos-
pital in June. But another complication devel-
oped, and he went to St. Louis for an operation
at the hands of one of the foremost specialists of
the country. It proved successful, and the sur-
geon was anticipating an early return home when
fatal conditions set in and it was impossible to
save him.
At the time he passed on, Dr. Taggart’s son,
Ludwig, was with him. The family, headed by
Thomas D. Taggart, Jr., member of the county
bar, started westward, but failed to reach St.
Louis in time. The survivors include Mrs. Tag-
gart and Mrs. Russell Kleinginni besides the 2
sons.
Dr. Taggart was born in Shenandoah, Pa., in
18 70, his parents being Thomas and Phoebe Tag-
gart. After graduating from high school, he en-
tered Jefferson Medical College, Philadelphia,
from which he graduated in 1896. Subsequently,
he served in the hospital connected with that in-
stitution, and in the surgical ward of the Phila-
delphia General Hospital. While in that city he
married Miss Anna Drusilla Watson.
In 1906, Dr. Taggart went to the shore resort
to practice and had remained there ever since.
He became interested early in the development of
the Atlantic City Hospital. Besides his surgicgl
practice he found time for civic activities, join-
ing the Elks, the Masons, and serving as a lieu-
tenant of the City Troop of Cavalry, a private
military company which was organized several
years ago, but has been disbanded. He was also
a member of the Atlantic County Medical So-
ciety.
795
J ournal of The Medical Society of New Jersey
Published on
the First Day of Every Month
Vol. XXVIII., No. 11 ORANGE, N. J., NOVEMBER, 1931 |j$rK&. Year
SURGICAL ASPECTS OF BILIARY
TRACT DISEASE*
John B. Deaver, M.D.,
Philadelphia, Pa.
In these days, when the medical world is
so prevention-minded, it is eminently fitting
to stress the surgical aspects of biliary tract
infection, inasmuch as early recognition of
the indications for operation means easier
surgery, lower mortality and, finally, the pre-
vention of morbidity.
The point of whatever contention exists
between surgical and medical minds obviously
centers about the indications for surgery.
At the same time, I dare say, that nowhere is
cooperation between physician and surgeon
more important for the patient’s welfare. This
applies particularly to chronic diseases of the
biliary tract, for opinions seem to agree, at
least in this country, that the earliest acute
manifestations of disease of this region are
best treated medically. It is interesting to
note, however, that abroad, and particularly in
Germany, many careful observers are opposed
to the interval operation for acute cholecys-
titis, for example, basing their argument on
the fact that the best end-results are obtained
from surgery in the acute stage, when the
process is localized. Furthermore, they con-
tend that waiting for a quiescent period gives
the infection time to spread to contiguous
structures, especially the common duct, pan-
*(Read in Asbury Park, N. J., June 4, 1931, at
the 165th Annual Meeting' of the Medical Society
of New Jersey.)
creas and liver, thus giving rise to the residual
manifestations that cloud the results of sur-
gical treatment in chronic cases. These resi-
dual effects are so frequently discussed at meet-
ings of this kind, and we have so often been
a party to the discussion, that we would hesi-
tate again to intrude them upon your atten-
tion. were it not that your having suggested
the title of this paper encourages us to believe
that you are aware of the importance of, and
are as much interested in the subject as we
are.
What are the surgical aspects of infection
of the biliary tract? Their beginning is
usually in the gall-bladder, since among the
most important and persistent vital effects of
chronic disease of the gall-bladder are hepati-
tis, cholangeitis. pancreatitis, and last, but not
least, common duct involvement. If we are
to fall in line with preventive work it should
he our endeavor to avoid these serious se-
quels.
It is a matter of common knowledge that
practically all cases of cholecystitis have an
associated hepatitis. No less familiar is the
fact that gall-bladder infection may be carried
from and to the liver through the portal or
the lymphatic route. In fact, from the affer-
ent route the liver may become involved from
any abdominal focus — appendix, peptic ulcer,
or colon, which may in turn involve the gall-
bladder; while, as a rule, from the gall-bladder
to the liver, infection is carried by way of the
lymphatics. The question as to whether the
primary infection resides in the gall-bladder
or in the liver has not as yet been definitely
determined. There seems to be as much evi-
dence in favor of the one as of the other
796
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
route. Taking it for granted, therefore, that
in a certain percentage of cases the liver has
become infected through the gall-bladder, it
seems logical to assume that with removal of
the gall-bladder the hepatitis will subside, and,
if so, removal of the gall-bladder will be ef-
fective in preventing further damage to the
liver. The vital point in this connection is
the difficulty of recognizing the presence of
an associated hepatitis in disease of the gall-
bladder. For the present, we cannot do so
with any degree of certainty. This may
change when the busy research workers pro-
vide us with as reliable a test for early distur-
bance of liver function as cholecystography is
for disturbed gall-bladder function. While
the icterus index and the Van den Berg tests
are indispensable for detecting latent jaundice,
we must remember that (except when the
common duct is involved) not all cases of hep-
atitis are jaundiced, so. the hepatic disease
may progress unrecognized until exposed by
surgery. Even when it is suspected clinically
by the common signs of hepatic insufficiency,
such as lassitude, so-called bilious attacks, etc.,
it is doubtful whether it can be effectively
cured by non-surgical means, such as drain-
age, cholagogues and the like. That, at least,
is our experience, based on the number of
cases of gall-bladder disease that eventually
are brought for operation.
In its early stage, the stage of metabolic
disturbance, disease of the gall-bladder does
not extend beyond the mucosa of the organ,
so that the cystic duct remains unaffected.
While in this stage, medical drainage should
be promising, especially when accompanied by
the proper regimen of rest and diet directed
toward altering the blood chemistry. There
are 2 points to be considered in this connec-
tion : First, the gall-bladder may have become
infected through the liver, and thus the hep-
atic disease may be already too advanced to
benefit by medical drainage. Secondly, catar-
rhal cholecystitis is comparatively uncommon,
since in most instances the disease resides in
the walls of the gall-bladder, and it is only by
removing this interstitial infection that the
ravages of infection can be checked, the chief
of which are choledochitis, hepatitis, chol-
angeitis, pancreatitis, and occasionally hepatic
abscess, or cardiac and renal derangement.
Among the serious possibilities of gall-
bladder disease, cholangeitis assumes import-
ance because of its tenacious chronicity, a ten-
acity which is explained by the fact that the
lesion of cholangeitis resides deep in the wall
of the bile ducts. The symptoms of cholan-
geitis are those of infection plus certain fea-
tures related to hepatic function. The mild
case presents fever, malaise, anorexia, jaun-
dice at times, and usually an appreciable, en-
largement of the liver. The same train of
symptoms, in fact, as is seen in catarrhal
jaundice, stone in common duct, and hep-
atitis, so that differentiation is not always
possible. Indications for operation depend
upon the surgeon’s experience in estimating
the patient's condition, and the degree of dis-
ability suffered by the patient. Some mild
case of cholangeitis may subside spontan-
eously. A similar acute judgment is required
in the more severe cases which are charac-
terized by septic temperature, deep jaundice,
profuse sweats, anorexia, nausea, vomiting
and marked enlargement of the liver. In
these, the margin of safe surgery is easily
overstepped. The physician acts best who
seeks a surgical opinion early in the early case.
The infection being interstitial, it can be cured
only by continuous, prolonged drainage, such
as can be obtained only by means of a T-tube
in the common duct. The logic of the treat-
ment is the same as applies to localized infec-
tion elsewhere in the body by the relief of ten-
sion and drainage, but with this difference, that
such localized infections are usually acute
conditions, whereas most of the lesions of the
biliary tract are a chronic, low-grade and well-
established infection which has led to more or
less functional derangement. Simple drain-
age of the gall-bladder will not suffice for a
cure in these cases. The gall-bladder must
be removed because the potential power for
future trouble lies in the infection retained
within its walls. So, removal of the gall-
bladder and T-tube drainage of the common
duct will be required, according to presenting
conditions. This applies likewise to common
duct involvement and to pancreatitis. We
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
797
very rarely use biliary drainage by cholecysto-
gastrostomy or cholecystoduodenostomv, not
only because we consider external drainage
more effective, but also because the stoma of
either type of anastomosis does not remain
patent for any length of time if the common
duct is not permanently obstructed. Further-
more, the presence of the anastomotic open-
ing may actually favor an ascending infection
from the stomach or duodenum into the gall-
bladder and the upper biliary tract.
The import of involvement of the common
duct cannot be overestimated in considering
the surgical aspects of infection of the bile
passages. Inflammation, as well as stone in
the duct, is generally the result of an antece-
dent cholecystitis. The presence of stone
causes a varying degree of biliary obstruction
which in turn increases the inflammatory re-
action and may ultimately result in stricture,
ulceration, etc. The effects of common duct
involvement are not only local but general,
due to the direct influence it exerts on the hep-
atic duct, through lymphatic absorption, and
on the function of the gastro-intestinal tract
and the pancreas. Stone in the common duct
is particularly serious because its possible ef-
fect on the hepatic duct may lead to cholan-
geitis or hepatic abscess as a result. Opera-
tion in such instances is done as a last resort'
and usually ends fatally. The surgery of the
common duct is so delicate and difficult that
it behooves the prevention-minded practition-
er to do all in his power to avoid this possibil-
ity in the treatment of his gall-bladder pa-
tients.
No doubt many of you are making up your
minds to ask the question — when does a gall-
bladder condition become surgical ? Let me
forestall this question. As already indicated,
early acute cholecystitis, except of course in
the presence of symptoms of perforation,
gangrene or malignancy, should be treated
conservatively, at least until the acute stage
has subsided. It is to the chronic cases that
the question is particularly applicable. As an
offhand answer, we would say that a chronic
case becomes surgical when, after a reason-
able period of systematic expectant treatment,
the attacks recur, or in the absence of such
treatment, after 2 or 3 acute attacks of gall-
stone cohc. Much depends, of course, on the
degree of disability in either case. Very of-
ten the patient will himself decide the question
in favor of operation. On the other hand,
oftentimes both the patient and the doctor are
of the procrastinating kind. That is to say,
an attack having subsided, they fondly hope
that no further recurrences will take place.
Unfortunately, this hope is scarcely ever real-
ized. Furthermore, it presents the risk of an
emergency operation when the site of the in-
fection, the gall-bladder, cannot be removed;
instead of the more safe interval cholecystec-
tomy with its infinitely greater chances of a
cure. For, as we all know, postoperative
morbidity is less after a radical than after a
conservative operation.
As already stated, prolonged cholecystic and
pericholecystic disease interferes with gastric
and duodenal motility, a condition which is
difficult both to diagnose and to treat. The
history usually comprises 10-15 years of at-
tacks of indigestion, consisting of epigastric
fulness and burning, sour eructions coming
on within an hour or so after meals, asso-
ciated with attacks of more or less severe pain
in the right upper abdomen. These attacks
at first occur at varying intervals, but grad-
ually the intervals grow less and the attacks
more severe, with nausea and vomiting as
concomitant features, occasionally followed by
a slight icteric tinge but no frank jaundice.
At operation, the pathology consists of a mass
of pericholecystic adhesions, the fundus of the
gall-bladder being fused into a hard mass to
which the tip of a high appendix may be ad-
herent and may contain pus; sometimes there
is also a pressure ulcer in the duodenum. This
may be an extreme example, but it occurs and
is the result of a prolonged pathologic process.
These are some of the surgical aspects of
biliary tract infection. If we are to keep in
line with preventive work, it is our duty to
make every effort to prevent their develop-
ment and progress.
DISCUSSION
Dr. Max Danzis (Newark) : One feels rather
diffident to open the discussion of a subject so well
presented by one of the master surgeons of the
world and one of the most convincing speakers
and great teachers.
798
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
There is no doubt that early recognition of gall-
bladder disease, combined with careful evaluation
of the indications for operation, will do a great
deal to minimize both the mortality and morbidity
resulting from prolonged biliary tract infection.
There are several instances in my own experience
in which prolonged suffering could have been ob-
viated and probably several lives saved, if the op-
eration had been performed soon after the presence
of a persistent and troublesome gall-bladder dis-
ease had been established. Instead of operating
upon these patients during the interval stage,
when a reasonably safe operation could have been
performed, we were compelled to operate either
for an empyema of the gall-bladder, with or with-
out perforation, obstructive jaundice due to com-
mon duct stone, or acute or subacute pancreatitis
associated with gall-bladder disease.
With our present improved knowledge of this
particular disease and with the development of
better diagnostic methods which aid the clinician
to arrive at a definite diagnosis in the majority of
cases of true cholelithiasis or cholecystitis, there
seems to be no real logical reason to submit our
patients to prolonged medical treatment, which
at best only alleviates and never cures the dis-
ease.
Every patient is entitled to palliative measures
during his first atack of cholelithiasis or cholecys-
titis. They should be kept under observation, dur-
ing and after the attack has subsided, so that the
character and severity of the infection are defin-
itely established; but as soon as the symptoms
become persistent, operation is indicated.
One should not operate during an attack of
acute gall-bladder colic, unless the pain continues
to recur, with a persistent rise of temperature,
associated with upper abdominal rigidity and a
palpable tender mass which shows no evidence of
any improvement for several days. The majority
of acute atacks subside under palliative treatment.
Instead of operating during the acute stage upon a
distended and thickened gall-bladder, associated
with inflammation of the upper abdominal peri-
toneum which makes extensive manipulation dif-
ficult and dangerous, one should wait until the
inflammation subsides entirely. The patient should
be given a chance to completely recuperate be-
fore operation is undertaken. Instead of doing a
palliative operation of cholecystostomy in the
acute stage, which may require re-operation la-
ter on, one can do a cholecystectomy with much
less risk to life and a better chance. for a com-
plete cure later on.
Hepatitis. It has been shown by many investi-
gators that very often the liver and biliary tracts
are involved in gall-bladder disease. Klemperer
and others have shown degeneration and necrosis
of liver in biopsies obtained from patients suf-
fering from acute catarrhal jaundice. They be-
lieve that the yellow atrophy sometimes seen in
these cases is a terminal event due to autolysis of
the liver cells by their own ferments, analogous to
their autodigestion seen in pancreatic leakage.
E. S. Judd, A. C. Nickel and W. L. A. Well-
brock studied the association of hepatitis with
biliary tract disease. They found that by submit-
ting a fair-sized piece of liver, taken at the time
of operation, and culturing it aerobically or an-
aerobically, positive results were obtained in 27
out of 37 cultures made from the liver substance.
In 30 cultures made of the gall-bladder, 47% were
positive. Their conclusions are that this condition
(of hepatitis) may exist in the liver “even when
recognizable change cannot be made out of the
gall-bladder or bile ducts”. They believe that
hepatitis may occur as a primary condition, giving
symptoms similar to cholecystitis, and that re-
moval of the gall-bladder in cases of primary hepa-
titis will relieve the symptoms.
In another series of 300 cases studied by E. R.
Judd, the same authors conclude that the major-
ity of surgically dissected gall-bladders in acute
or subacute cholecystitis contain pathogenic bac-
' teria.
Kolster and Goldzeiter have also made similar
studies with somewhat similar results.
Value of Glucose in the Pre-operative Stage. Ex-
perimental work on animals by Graham, Opie, Al-
ford, Mann, of the Mayo Clinic, and others, has
demonstrated that there is a definite increase in
the resistance of animals when the glycogen con-
tent of the liver has been increased by glucose
feedings before exposing the animals to the toxic
and infectious substances used for the experimen-
tal production of liver degeneration and yel-
low atrophy. It has been shown in the Mayo
Clinic that dogs whose livers were removed for
experimental purposes, and who were at the point
of death, with a very low sugar content, recovered
temporarily from their moribund state upon the
intravenous administration of glucose. These ex-
perimental observations formed the basis for the
pre-operative preparation and the postoperative
treatment in gall-bladder disease by administration
of glucose solution. It serves to protect the liver
cell against the rapid autolysis seen in yellow
atrophy, which sometimes occurs as a terminal
complication and it lessens the possibility of hy-
poglycemia sometimes seen in these cases, and
which is a factor in the so-called liver shock.
We have had several opportunities to demon-
strate to our own satisfaction the value of intra-
venous administration of glucose in cases of se-
vere shock associated with acute cholecystitis. In
2 cases seen recently, the patients presented such
alarming symptoms of shock that a diagnosis of
acute pancreatitis was considered. The extremely
rapid and small pulse, very high temperature,
moderately cyanosed skin, dry tongue and mild
#delirium, justified the consideration of such a diag-
nosis; but the absence of generalized rigidity, the
presence of localized upper abdominal tenderness,
and a palpable mass, led us to make a diagnosis of
cholecystitis with associated liver shock. Opera-
tion at that stage seemed to be most hazardous.
These patients received frequent intravenous in-
jections of 1000 c.c. 5% glucose in the first 24
hours. The improvement in their condition during
the first 24 hours was remarkable. Symptoms of
shock gradually but steadily disappeared, and after
1 week’s rest in bed, combined with the adminis-
tration of large quantities of fluid, cholecystectomy
was successfully performed.
Non-Surgica.l Drainage. My experience with non-
surgical drainage has not been a very satisfactory
one. Very frequently I have operated upon patients
who have had repeated non-surgical drainages
with hardly any improvement, and certainly no
cure. The difficulty with the non-surgical biliary
drainage method is the promiscuity with which it
is used. I presume there are certain instances
where some benefit may be derived from its use,
but in the clean-cut cases of troublesome cholecys-
titis or cholelithiasis, it is just as useful as is the
ice-bag in the cure of appendicitis. Once the
gall-bladder walls become diseased, it should be
removed. Study of the gall-bladder function was
made of those cases subjected to cholecystostomy
and it was found that, out of a number of patients
submitted to cholecystography, at different in-
tervals following the operation of cholecystostomy,
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
799
only 3 To gave normal responses. The vast ma-
jority showed absent or impaired function. Even
with those who remained symptom-free, the
cholecystograms indicated impaired functions.
Such gall-bladders constitute a potential source of
future trouble. But even at the present stage of
our knowledge some challenge the value of
cholecystectomy as a rational method of curing
gall-bladder disease.
I recently came across a statement in one of our
surgical journals, which read as follows: “In the
present stage of knowledge of liver function and
pathology, it is just about as reasonable to do a
cholecystectomy on a functioning though infected
gall-bladder, as to cut off the tail of a sick dog.”
The use of the T-tube for prolonged drainage in
cases of cholangeitis with obstructive jaundice due
to large stone in the common duct, has been
demonstrated in 3 of our cases to be a most satis-
factory means of relieving the inflammatory con-
dition in and about the ' biliary ducts. In the case
of an elderly woman, jaundiced for 3 months as a
result of a large stone in the common duct, the
tube was left in situ for 6 weeks. The recovery
was rather slow but complete in all of these cases.
These patients usually come to operation in a very
poor state of health after prolonged course of
medical treatment. They figure most prominently
in our mortality and morbidity statistics. Early
diagnoses and prompt surgical intervention in
clear cut cases of gall-bladder disease will greatly
reduce the morbidity and mortality of this con-
dition.
Dr. J. Montgomery Deaver: I heartily agree with
everything Dr. Danzis has said. Particularly about
non-surgical drainage in that operation. In these
cases of gall-bladder disease, if the bile is cultured
it is nearly always negative, but cultures of the
gland and gall-bladder wall are positive in over
50% of cases and mostly show some form of
streptococci. If that is the case, drainage will
hardly clear the infection.
The other point is about glucose. In the Dan-
kenau Clinic it is given routinely pre- and post-
operatively in all bad gall-bladders. It not only
tends to prevent liver shock but it shortens the
bleeding time, and coagulation time, and has re-
placed the use of calcine.
VALUE OF DUODENAL TUBE DRAIN-
AGE OF THE BILIARY SYSTEM
IN THE TREATMENT OF VAR-
IOUS DISEASES AND DIS-
ORDERS OF THE LIVER"
B. B. Vincent Lyon, M.D., F.A.C.P..
Philadelphia, Pa.
In 1923 I published a monograph entitled
“Non-surgical Drainage of the Gall-Tract”,
which presented a method of value in the
diagnosis and treatment of affections of that
region. The choice of the title was unfor-
* (Presented before the 165th Annual Meeting
of the Medical Society of New Jersey, held in As-
bury Park, June 4, 1931.)
tunate because this method became popularly
known as non-surgical drainage of the gall-
bladder. Had the title given to this paper
been chosen instead, it is probable that less
acrimonious debate in various medical and
surgical circles would have taken place. While
this discussion has been useful in some re-
spects, nevertheless it caused the loss of valu-
able time because it confined the problem
chiefly to gall-bladder disease, by all odds the
least important, although the most common,
of all diseases or dysfunctions of the biliary
system when considered as a whole, and par-
ticularly so when considered from the stand-
point of preventive medicine. Had the 123
pages of case reports at the end of the writer’s
monograph been read with care it would, even
then, have become evident that duodenal tube
drainage of the biliary system opened up a
new avenue of effective treatment for various
diseases of the liver and other associated com-
ponents of the biliary system.
The chief purpose, therefore, of this paper
is to again call attention to the efficiency of
the duodenal tube in the treatment of various
diseases or dysfunctions of the liver and its
ducts, for the moment leaving the gall-
bladder out of the discussion. Whether we
are internists or surgeons, general practition-
ers or specialists, our aims are the same,
namely : to prevent or cure disease or to im-
prove the function of an organ when in a
state of dysfunction, but not at the expense
of injuring or destroying the underlying
physiology upon which return of function will
depend.
Apart from the gall-bladder, which, under
some but not all conditions, does require re-
moval in order to cure or benefit the patient,
I wish to show that certain diseases in which
the biliary system is directly or indirectly in-
volved can be more effectively treated with the
assistance of the duodenal tube than by other
measures now customarily employed, whether
medical or surgical. If the surgeons would
add the duodenal tube to the equipment of their
wards, and would themselves, or have some
member of their staff, master the technic of
its proper use, some patients would not re-
quire surgical service; many, thus preopera-
soo
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
lively prepared, would much better withstand
operative shock and postoperative discomfort ;
many, thus post operatively treated, would es-
cape some degree of postoperative morbidity ;
and a few would dispense with the services
of the undertaker. With it, one can do rela-
tively less harm even if the job is bungled.
One cannot say the same of the scalpel.
The liver, which cannot be removed, can be
surgically drained. Such drainage means re-
moval of infected or toxic material from the
body. It is a surgical and medical axiom that
when external drainage is practicable it yields
better results than internal drainage. The
simplest illustration is the lancing of a boil.
The reason for this is that in internal drainage
some reabsorption of toxins, or some further
distribution of infected tissue, takes place and
retards or prevents recovery. If there are 2
methods of attacking the problem in any indi-
vidual case, and each method can be proved of
value, the least dangerous to life or subsequent
ill health should be chosen. This has been
found true, for instance, in the management
of peptic ulcer after 30 years follow-up of that
subject.
Since 1925, abdominal surgeons have be-
come more “liver minded”. Many papers have
been published on the surgical treatment of
hepatitis, cholangeitLs, and, to some extent,
cirrhosis. Surgical indications, on which sur-
gical success is based, demand pathology.
Such organs as can be removed without imme-
diate death or too immediate postoperative
mortality are removed. The history of the
subject indicates that during certain periods
many such organs have been needlessly sacri-
ficed because of surgical over-enthusiasm or
misjudgment. On the other hand, in late
biliary tract disease there may be and. fre-
quently is an already co-existent hepatitis, cho-
langeitis or both, and in some instances some
degree of cirrhosis. Speaking broadly, this
would appear to substantiate the claim of some
surgeons that they receive their gall-bladder
patients too late to accomplish as good results
as an earlier cholecystectomy would have
yielded. I have no doubt that in many in-
stances this is true, and it undoubtedly con-
tributes to the postoperative morbidity. Never-
theless, postoperative morbidity is still too
frequently ignored. A large degree of such
postoperative morbidity can be far worse for
the patient or his family than his immediate
death or a comparatively speedy exitus.
As painful as such a statement may be, we
gain nothing in further progress unless we
face the facts. For this reason I believe it im-
portant to briefly discuss this. No matter to
what extent my experience may differ from that
of others, I offer my own statistics, as follows:
In a recent review of 1000 cases of biliary
tract disease up to January 1. 1929, histories
revealed that 128 of those patients had been
operated upon before I saw them. They were,
therefore, presenting themselves with second-
ary morbidity involving the biliary system,
and of various degrees and types consistent
with cholecystectomy, cholecystostomy and
choledochostomy. Of those 128 patients, 32%
had been subjected to 2, and 13% had under-
gone 3 to 9 abdominal operations ; and 25 of
the 128 previously operated upon were again
referred by me for further gall-tract surgery;
among whom there were 3 deaths, or 12%
mortality; while a large majority of the other
103 patients were restored to health by non-
surgical methods. In addition, there were 68 in
this series referred by me for primary opera-
tion ; being chosen with considerable care both
for surgical indications and surgical risks.
About 85% of them were for cholecystectomy.
The surgeons selected were all master surgeons
or, at least, in Class A group of surgeons. Of
these 68 patients, 7 died, or 10.3% mortality.
Of the 61 who recovered, 22 (36%) were re-
turned to satisfactory health by operation
alone; 39 (64%), however, developed post-
operative morbidity that returned them to my
observation. Although the morbidity varied
greatly, many of them were cases of residual
cholangeitis and hepatitis which responded
satisfactorily to postoperative duodenal drain-
age because they were recognized early by
duodenal tube check-up.
I have, in earlier papers, stated the great
desirability of rechecking by duodenal tube
the presence or absence of latent or smoulder-
ing inflammation or infection in the liver or
the ducts 6-10 weeks after gall-bladder opera-
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
301
tions. There is no accurate way of doing this
save by the duodenal tube, the microscope and
the culture flask. I believe it should be part
of the responsible duty of the surgeon to his
patient to see that this is done. If trouble is
found, a few duodenal tube drainage treat-
ments may be all that is necessary to prevent
re-operation, a matter discouraging to both
patient and doctor. This accounts for the 196
surgically managed patients in this series of
1000 cases.
The remaining 804 patients have been treat-
ed non-surgically by various combinations of
methods; a large majority of them had duo-
denal drainage at some time or other for
periods of 3 months to several years, with un-
usually satisfactory end-results. Of these,
there were 621 cases of Grade I to Grade III
cholecystitis, or catarrhal conditions of gall-
bladder, cystic, or other extrahepatic ducts,
which are omitted from discussion except
where they fall into one or another of the
liver groups with which this paper is primarily
concerned. None of these patients, so far as
I know now, has had occasion to appeal to
surgery, although my records show that I
tried to persuade 45 of them to accept surgi-
cal treatment ; but they continue to be satisfied
with the results achieved. And these results
do not compare unfavorably with those ob-
served in my«surgical group.
Recitation of the cases to be presented appears
to show that more can be accomplished in the
general management of such patients than has
usually been possible by utilization of the
methods customarily employed. Because the
case reports represent diversified pathology,
and various dysfunctions, and yield apparently
unrelated clinical pictures, it is obvious that
one must search for the “common denomina-
tor”. A large part of my clinical evidence
points to the liver, as the “common denomina-
tor”. Therefore, the next step is to review
the various accredited liver functions and see
which of them are most frequently affected.
The following 7 functions of the liver have
been generally accepted :
(1) In health to secrete a fluid called bile,
which is useful to normal digestion; in dis-
ease to assist in excretion of various poisonous
substances (secretory-excretory function).
(2) To assist in the metabolism of carbohy-
drates ; here it performs an absolutely vital
function in maintaining the blood sugar level
(glycogenic function).
(3) To assist in the metabolism of proteins
to the extent of forming urea, destroying uric
acid, and de-aminizing the amino-acids (pro-
teogenic function).
(4) An automatic chemical laboratory to
destroy, neutralize, or synthesize various
poisons brought to the liver (detoxifying
function) .
(5) To destroy, or render harmless, bac-
teria brought to the liver by the blood (bac-
teriacidal function).
(6) To store a part of the fat taken as
food and release it when required. Most im-
portant, it desaturates fats, rendering them
labile for metabolism (lipogenic function).
(7) To assist in iron and copper metab-
olism.
Although these various functions appear to
be quite specific, it is highly probable that in
many sick persons several of them may over-
lap or interlock ; that is, when there occurs a
primary breakdown of one function, there
may soon occur a breakdown in one or more
others. This is evidenced by the fact that no
one test of liver function gives us full infor-
mation regarding total function, but only the
data that the one test is supposed to yield.
Hence the importance of carrying out several
tests. For the purpose of this paper I must
go into more detail in regard to the detoxify-
ing and bacteriacidal functions of the liver,
for it is with those functions that my thesis is
chiefly concerned.*
The Detoxifying Function
Recent work has indicated that the liver is
capable of destroying many toxic substances
but, in the long continued fixation of these in-
jurious products, progressively destructive
changes in the liver tissue also take place. For
example, certain substances highly poisonous
when administered hypodermically are much
less harmful when administered by mouth
*The paragraphs dealing with those 2 functions
have been taken from the writer’s revision of the
chapter dealing with Diseases of the Liver, Gall-
bladder and Biliary Ducts, in the last edition of
Osier’s Modern Medicine. Vol. 3, p. 722.
802
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEV
Nov., 1931
(curare and nicotin). Some toxic substances
seem to have a selective affinity for the liver,
producing a widely spread fatty degeneration
(phosphorus phenvl-hydrazin, and more recent-
ly ato'phan and cinchophen) or acute cellular
necrosis (chloroform). The liver is believed to
exert a similar detoxifying action on the toxins
of certain bacteria and on the products of bac-
terial putrefaction in the intestine, such as
indol, skatol and phenol. In some cases these
poisons are excessive in amount, or in viru-
lence, and the liver is unable to handle them.
There is no doubt that in disease the detoxify-
ing function of the liver becomes more or less
impaired, but there are no trustworthy diag-
nostic tests of this function. The phagocytic ac-
tion of the Kupffer cells, assisted by certain
cells of the spleen and of the lungs, have been
shown by Opie to play an important part in
the binding or fixation of inorganic particles
(bacteria, colloid material and certain sub-
stances observed in the blood plasma). Clini-
cally, anthracotic pigmentation of the liver is
often found in advanced pulmonary anthra-
cosis. There seems to be some elective ac-
tivity on the part of the lobes of the liver to
fix particulate matter brought to it in the
portal vein. For instance, after injecting
India ink into the splenic vein, deposition of
such pigment is found largely within the left
lobe, whereas the same substance injected into
the superior mesenteric vein will be found de-
posited largely in the right lobe of the liver
(Riemann). This may be due, however, to the
mechanics of the blood circulation current in
the splenic trunk of the portal vein, as suggest-
ed by Bartlett. This seems to throw additional
light upon the clinical association existing be-
tween enlargement of the left lobe of the liver
in syphilitic gumma, in echinococcus cyst, and
in certain splenic diseases, such as Band’s dis-
ease, or hemolytic jaundices with splenomegaly ;
whereas, the hepatitis and cirrhosis resulting
from chronic focal infective disease of the ap-
pendix, duodenum or gall-bladder, is found
chiefly in the right lobe. Likewise, a solitary
abscess due to entameba is more often in the
right lobe.
Bacteriacidal Function
A healthy liver seems to possess the power
of destroying, or rendering harmless, bacteria
which entered the body by way of, or are
elaborated within, the gastro-intestinal tract.
It aids in destroying bacteria entering by way
of the circulating blood, for many experi-
ments have shown that the liver, assisted by the
lungs and spleen, exerts an important func-
tion in removing bacteria from the blood
stream. Here, too, the cells of Kupffer ap-
pear to have the most active phagocytic power.
As in other functions of the liver, long con-
tinued assaults tend to wear down the bac-
teriacidal power and degenerative changes and,
later on, destructive cellular lesions develop.
Many workers have demonstrated that in bac-
terial focal infections of the appendix, in duo-
denal (ulcer) and gall-bladder infections, as
well as in the intestines themselves (colitis),
the liver, chiefly the right lobe, becomes chron-
ically inflammed and cellular destruction grad-
ually occurs. Sections from the liver removed
at operation for other lesions show well de-
veloped hepatitis in the more acute cases and
various grades of hepatitis plus cirrhosis in
the more chronic cases (Heyd, Graham and
others). These findings help to explain some
of the symptoms occurring in patients with
hepatic intestinal toxemia.
In connection with the 2 foregoing func-
tions, I have been impressed with some obser-
vations that appear to explain the production
of certain types of liver disease or dysfunc-
tion, as well as the postoperative morbidity
which occurs after cholecystectomy. One is
concerned with the contrast in effectiveness of
external vs. internal drainage of bile. Perhaps
it will clarify the matter somewhat if I refer
now to the 3 vicious circles in biliary disease.
The first vicious circle is concerned with
the lymphatic distribution which exists be-
tween the liver, gall-bladder and pancreas. If
there exists a mural or interstitial cholecystitis
of bacterial nature, the gall-bladder becomes a
genuine focus of infection and the lymphatic
distribution re-routes the infection to the liver
and pancreas and back again to the gall-blad-
der. Cholecystectomy should break this first
vicious circle.
Xov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
803
The second and third vicious circles are con-
cerned with absorption of bacterial and chemi-
cal toxins from the splanchnic venous bed and
from the abdominal lymphatic circulation.
In patients who do not make a complete re-
covery by cholecystectomy, and who show sub-
sequent morbidity, my hypothesis is that the
second and third circles are operating and that
the bile contains toxic substances or viable
bacteria, which pass into the duodenum pre-
sumably to exit from the body by way of the
fecal current. But, during their passage
through the intestines, as is well known,
part of the toxic dose is reabsorbed by
the mesenteric blood supply and carried
back by the portal vein to laboring liver cells,
and a portion is reabsorbed by the mesenteric
lacteals and thence by way of the thoracic
duct with no detoxifying buffer, such as the
liver, into the tired or toxic heart by the in-
nominate or subclavian vein. Again, some of
the viable bacteria focalized in the liver, in
bacterial hepatitis or cholangeitis, drain out
with the bile, pass through the intestinal
mucous membrane into the mesenteric capil-
laries, and thence directly to the liver by way
of the portal vein ; some of them directly in-
fect the small and large bowel and thus, by
dissemination, produce an enteritis, colitis or
both ; the toxins of some bacteria may be
absorbed by the mesenteric lymphatics and be
carried into the systemic blood, finally reach-
ing the heart to contribute in producing toxic
myocarditis with sufficient decompensation to
produce chronic passive congestion in abdom-
inal viscera, notably the liver.
Thus, briefly described, is my hypothesis of
the 3 vicious circles in biliary tract disease. It
is not unlikely that the same or a similar cycle
of events is concerned in the toxemias of
pregnancy and of uremia, and that here, too,
the liver plays an important role in the tox-
emia, and that such patients might be im-
proved by external biliary drainage. If the
above hypotheses are tenable, the contrast be-
tween the effectiveness of external and in-
ternal drainage of bile becomes more readily
understandable. On the other hand, many
doctors believe that internal drainage is all
that is necessary and rely upon various cho-
leretics or hepatic secretogogues, and their
name is legion : such as calomel, Epsom salts,
Pluto water, Carlsbad water or salts ; the
jalap, gamboge, colocynth and bryonia of
older days which are now rarely used ; various
pills of bile salts or bile acids (often reinforced
with aloin, phenolphthalein or cascara), such
as veracolate, taurocholate, taurocol, holadin,
zilatone, pancrobilin, caroid and bile salts, exi-
col, felamin, agocholan, etc. Any of these,
given by mouth, are alleged to accelerate bile
manufacture by the polygonal cells of the
liver, or to increase the amount of bile dis-
charged from the liver and gall-bladder, and
thus increase internal drainage. But do the
patients get well? Are they cured? In our
experience, if such measures alone are used,
they produce in the long run little, if any, im-
provement and may have merely added the
constipation-laxative habit vicious circle to
what they are already suffering.
Another group of doctors, still skeptical of
the duodenal tube, depends largely on certain
dietetic principles. If there is some degree of
jaundice, they advocate a reduced protein and
largely fat-free diet because of increased
nitrogen retention due to lessened proteogenic
function, and because of impaired fat diges-
tion due to lessened bile flow. If there is no
jaundice but evident cholecystitis, they advo-
cate a fat-full diet because the gall-bladder
physiologically best empties its bile in re-
sponse to fat-rich foods. Both of these views
are sound as far as they go. But do they go
far enough?
If the jaundice is due to catarrh or infection
in extra- or intra-hepatic ducts, the duodenal
tube will assist in clearing it faster in conjunc-
tion, if you will, with some hepatogogue and
a fat-low diet. This spares the liver cells,
and at times the pancreatic cells, many extra
days of pressure damage; a cardinal principle
to be remembered. If the gall-bladder is in-
flammed in mucous membrane or wall, the
patient has learned that he is intolerant to
fats, because they increase his digestive dis-
comfort, and he tells us that he has had to
give up his eggs, cream, bacon, butter, olive
oil or fried greasy foods. If he has small
gall-stones, such foods tend to move a stone
804
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
into the cystic duct and he has learned to ex-
pect an attack of biliary colic. Therefore, as
sound as the theory is, it is not always good
practice to follow it. We have found it bad
practice to squeeze a boil not only because it
traumatizes surrounding tissue but because it
hurts. We have found it bad practice to
purge in appendicitis because intestinal over-
activity literally flogs the appendix, tends to
increase inflammation, spread infection and
encourage perforation. I am not at logger-
heads with the theory but assert that it does
not go far enough, for I can say that 7 out
of every 10 patients referred to me have gone
through several years of such medicinal and
dietetic management and their morbidity re-
mains the same or is increased. I assert that
something is missing and believe that “the
something’’ is the effective therapeutic value
of the duodenal tube. When such patients reach
me, if they do not require operation, I do not
necessarily discard such medicines or diets
but merely add duodenal tube management,
and I see them improve and they know how
much better they feel. Flushing the duodenum
directly with hot water or salt solution, and
stimulating with repeated small douches of
magnesium sulphate, peptone or olive oil, not
only relaxes tension in the duodenal wall, and
relaxes Oddi’s sphincter, but encourages
gentle contractile effort of the gall-bladder
and promotes freer bile flow from the liver,
gall-bladder and ducts. But the essential
point, I believe, is that the bile is drained ex-
ternally. just what does external drainage of
bile accomplish that internal drainage does
not ?
Assuming for the moment that my hypo-
theses are correct, I must argue that in re-
moving from the body by means of the duo-
denal tube various amounts of bile — from
pints to gallons — I am also removing appre-
ciable amounts of toxic ‘substances, appre-
ciable numbers of unkilled, pathogenic and
often highly virulent bacteria.* These, thus
removed from the body as they reach the
duodenum, are therefore not available for re-
absorption in the lower intestinal levels for
return to the liver ; they are, in diminished
♦Consult Chapter 19 “Non-surgical Drainage of
the Gall-Tract" — Lea & Febiger, Philadelphia, Pa.
amounts and numbers, less likely to devitalize
intestinal mucosa and distribute infection;
which may be the reason why patients so treat-
ed, gradually, sometimes rapidly, occasionally
in most spectacular fashion, lose the clinical
picture of toxemia and become vastly im-
proved. and not a few are seemingly cured.
And this is quite a lot to say of essentially
chronic disease or long continued dysfunction.
By analogy, I can further develop my argu-
ment. How many of you remember that in
the older days, when surgeons relied on drain-
ing rather than removing the gall-bladder, we
marvelled at the clinical improvement in the
toxic heart and the toxic kidneys ; that the
extra systoles and dropped beats and disco-
ordinated action of the heart often miracu-
lously vanished; that the urinary albumin,
ketones and casts disappeared while the pa-
tient was in the hospital and still discharging
bile through the sewed-in rubber tube, or was
saturating the dressings after the tube loosen-
ed its stitches and fell out? And how many
of you were overwhelmed with disappoint-
ment or discouragement when half a year to
several years later the patient returned to
your observation with a nicely healed abdom-
inal scar but complaining of much the same
symptoms as before, and you found the heart
again arhythmic, the patient “heart conscious”,
and the kidneys reflecting the renewed tox-
emia? Could this conceivably mean that after
internal biliary drainage was reestablished in
the presence of residual hepatitis or wliat not,
and reabsorption of toxic loads on the liver,
heart, kidneys, intestines, brain, blood-vascu-
lar and neural symptoms had accumulated,
that the return of the clinical picture was due
to this?
I admit the desirability of evacuating by the
scalpel an echinococcus cyst or a localized
amebic abscess of the liver, but, for the fol-
lowing reasons, I do not admit the desirability
of surgically draining the common duct by T-
tube for diffuse disease of the liver such as
occurs in hepatitis, cholangeitis lenta, cir-
rhosis, or toxic manifestations of liver dys-
function. because there now is available an
alternate method of lesser risk and proved
value. All agree that common duct surgery
is the most difficult gall-tract surgery and
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
805
yields the highest mortality rate, and from my
personal experience yields the highest mor-
bidity rate. Injury to the common duct, even
by experienced surgeons, is not uncommon
and when it does occur it leaves the patient far
worse off. When there is irreducible obstruc-
tion between the liver and Oddi’s sphincter we
must rely upon surgery alone. Otherwise, I
advocate more extensive use of duodenal tube
drainage because of its greater safety, its
greater effectiveness if measured in terms of
amount of bile drained, and finally because of
the satisfactory results that have been
achieved.
Several years ago. and again recently, I
interrogated the surgical divisions of several
hospitals in regard to the amount of bile-
drainage secured in 24 hours after choledo-
chostomy. This averaged slightly less than 500
mils. In a similar survey of our patients whose
livers were drained and the bile mixture col-
lected by duodenal tube, the average yield in
24 hours was over 1500 mils, in many in-
stances 2000 to 3000 mils. Admitting that such
a mixture represents salivary, gastric, duodenal
and pancreatic fluid, as well as bile, our
studies have indicated that when the patient
is suitably controlled with atropin or bella-
donna, or with sedatives, at least 2/3 of it is
bile. Comparatively seldom do we recover
all of the bile secreted by the liver ; some por-
tion of it usually escapes recovery by the
tube, because the feces only rarely become
acholic. This observation makes me believe
that the liver secretes more bile in 24 hours
than the 600 to 1000 mils accredited to it in
modern monographs of medicine.
The present method of more intensive
drainage of the liver and ducts was described
in 1925. Since then there have been only
minor modifications in the technic. It is
essentially a therapeutic procedure and was
designed to emulate and afford an alternative
method to surgical common duct drainage. Ob-
viously, it must be restricted to patients who
do not have irreducible obstruction of bile
flow to duodenum, such as stricture of the
common duct, cancer at the head of the pan-
creas, or extensive adhesions obstructing the
bile flow. For such patients, surgical me-
chanics are better adapted provided an able
.and experienced surgeon wields the scalpel.
Even in such hands, the risks the patient faces
are not negligible; and in less able hands the
results are often truly ghastly.
Experience with it has shown that if there
is no mechanical obstruction of extrahepatic
ducts, duodenal tube drainage will secure as
much bile, probably twice as much, as can be
obtained by surgical drainage; and with far
less local traumatism. Thus, more effective re-
lief of the diseased liver or ducts is afforded.
It is the therapeutic method of preference in
cholangeitis, hepatitis, incipient hepatic or pan-
creatic cirrhosis, and the various conditions
described in the case reports. Its rationale
and the 2 vicious circles it is designed to break
have been broken as briefly described above.
It is generally well tolerated by the patient
and will be found most beneficial. It repre-
sents roughly 24 hour drainage in each cycle
of 48 hours. In sufficiently sthenic patients,
these cycles may be repeated for 2, 3, or even
6 or more weeks. In the asthenic patient,
2 or 3 days of rest may be desirable between
drainage cycles. It has the advantage of
being stopped or resumed at will over longer
periods than is possessed by surgery without
detriment to the patient. But, more important,
it avoids both operative and postoperative
shock so serious in liver disease, and it avoids
all possibility of injury to the common duct,
such a real disaster to the patient and his fam-
ily, as well as to the reputation of the sur-
geon.
The drainage nurse in charge should be
efficiently trained. With proper adherence to
technic, more than a gallon of bile mixture
per week can be secured in many cases. I
believe that this removes much toxic material
from the patient, with corresponding clinical
improvement.
In the severely jaundiced patient, caution
should be observed that the liver be not “de-
compressed" too rapidly by removal of too
large quantities of bile. Otherwise, cholemia
or a state of hypoglycemia may be produced,
with symptoms similar to those occurring in
Mann’s hepatectomized dogs. This can be
prevented or controlled by an occasional glass-
806
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
ful of orange juice or lemonade containing
1 to 3 tablespoonfuls of sugar; or in emer-
gency 25 gm. of glucose may be given intra-
venously.
I shall now report on a group of 639 patients
in whom the biliary and associated systems
were directly or indirectly involved, and who
have been under observation for sufficiently
long periods to submit them for appraisal in
support of my thesis. This group is subdi-
vided into : 146 cases of hepatitis and cho-
langeitis ; 387 cases of hepatic-intestinal
toxemia ; 1 1 cases of a group featured by
epileptic-like convulsions and unconsciousness ;
95 cases of early cirrhosis of the liver. In 26
patients, of this last group, the livers have
been inspected at operations for removal of
the gall-bladder or appendix, or for peptic
ulcer, and have shown gross changes charac-
teristic of the earlier stages of cirrhosis.
Case reports of one or more patients rep-
resentative of the various groups are submitted.
1 wish to present subsequently a more con-
densed statistical report of the entire group.
The case protocols presented have been chosen,
not so much for their uniqueness, because,
save one, they could be duplicated many
times, but to emphasize by them the fact that
the duodenal tube is a most important agent
in combating the progressive nature of their
disease.
The first 2 reports are representative of se-
vere forms of hepatocholangeitis, in one of
which the result of treatment was permanently
successful, and in the other temporarily help-
ful.
Case Histories
Case No. 501. Miss A. I., referred by Drs.
Gibbon and Despard, was 17 years old when
first seen April 2, 1917, suffering with an in-
fection of liver and bile ducts. There was
sufficient inflammatory edema of the common
■bile ducts to cause obstruction. She had been
subjected to 3 major gall-tract operations and
2 minor operations in 3 years. In addition to
this, she had 6 other hospital admissions, sur-
gical and medical services, for nonoperative
measures for post-surgical sequels, with diag-
noses ranging from abdominal adhesions to
hysteria and surgical neurasthenia. She had
been treated by bed-rest, external applica-
tions, salicylates, urotropin, morphin, codein,
sodium phosphate, nux vomica, cascara, calo-
mel and other drugs, and had been given var-
ious modifications of diet, with at best only
palliative effect. At the end of this time she
still had a chronic, infective hepatocholan-
geitis, punctuated with exacerbations of the
most characteristic type. The infective ageffi
was the Bacillus pyocyaneus, which had been
recovered from her surgical cholecystectomy
for empyema 5 years previously. During the
spring of 1917, while in an acute attack, the
surgeons in charge, feeling that they had done
all that was possible, transferred her to our
service.
She was definitely septic, under-nourished
and intensely jaundiced ; with a leukocytosis
ranging between 17,000 and 26.000 and low
polvnuclear resistance. She was suffering
with acute paroxysmal upper abdominal pain
and persistent nausea and vomiting. The
muscles of her upper right quadrant were
rigid and exquisitely sensitive to both light
and deep palpation. She presented the pic-
ture of a case that would be considered clearly
surgical if it were not for the fact that she had
already had her gall-bladder surgically drained
for an acute empyema, in 1912; that 6 months
later her gall-bladder had been removed and
her common duct drained ; that 13 months
later her common duct had been drained a
second time and several small stones were re-
moved which had probably formed in the duct
as the result of biliary stasis associated with
persistent infection and duct obstruction. The
surgeons still had vivid recollections of the
difficulties encountered in the 2 last opera-
tions in exposing the operative field on ac-
count of adhesions. This, then, was the first
patient upon whom duodenal tube drainage
of the biliary system was attempted. Al-
though this case has already been reported
in the writer’s monograph, in 1923, I wish to
add an additional 8 years’ “follow-up” and to
again direct attention to the fact that it cer-
tainly was not the type of case in which one
would expect much success from a new and
untried method of treatment.
This patient’s obstructed common duct was
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
807
unplugged bjr the local douching of the duo-
denum with magnesium sulphate and by the
use of hot, bland inflammation-allaying solu-
tions of boracic acid and Ringer’s salt. After
over-coming the duct obstruction, we recover-
ed thick, turbid, greenish-brown bile contain-
ing many pus cells, much inflammatory debris,
crvstalline elements and bacteria. The B. pyo-
cyaneus was isolated in pure culture from
this bile.
After the common duct had been unplugged,
it was kept open by continual duodenal tube
drainage several days, with direct disinfection
and cleansing of the duodenal zone 3 or 4 times
a day and jejunal feedings every fourth
hour. After 1 week of this schedule, biliary
drainage for 2 hours, followed by duodenal dis-
infection, was practiced ei^ery second day. By
the third day the critical picture of this pa-
tient materially improved ; paroxysmal pain
subsided with the establishment of biliary
drainage ; septic temperature dropped, muscle
rigidity relaxed, intense jaundice lessened,
and the leukocytosis gradually subsided. Dur-
ing the next 4 weeks there were several milder
exacerbations but from then on her final re-
covery was uninterrupted.
Aside from general supportive measures
and the use of an autogenous vaccine given in
repeated courses, she received no other treat-
ment except biliary drainage.
After a 2 months’ period of hospitalization
she reported to the Out-Patient Clinic for
biliary drainage 3 or 4 times a month through-
out 1917-18, and thereafter at less frequent
intervals. Now and then there was a ten-
dency to transient jaundice, persisting until
1920, but no return of the chills, fever or
sweats. . She has now remained well for 1 1
years. She has had drainage about once a
year since then to appraise objective findings.
The Bacillus pyocyaneus has never again been
recovered. She has married and has borne 5
children during the past 10 years. She was
followed with interest over the first preg-
nancies because of an apprehension that such
an occurrence might overload her liver and
precipitate a relapse. This, however, never
occurred despite the fact that over a period of 8
years her liver had been severely damaged.
This indicates that the hepatic margin of re-
serve is very great, and that more hope for
ultimate cure can be held out for such pa-
tients, particularly in younger decades, if they
receive adequate treatment.
Case A ro. 2350. Mr. R. S., referred by Dr.
Damon B. Pfeiffer, was 59 years old when
first' seen April 4, 1930. Chief complaint was
chronic obstructive jaundice for 2 years ; chil-
liness ; feverishness ; nausea and vomiting ;
loss of weight. In 1921 he had 3 gall-stones
removed and a cholecystostomy with a satis-
factory result until September 1927 when
gall-stone colic recurred and at operation a
long stone was found tightly impacted in the
cystic duct. It probably required a low cystic
duct ligation, thereby injuring the common
duct, since 3 days later this patient became
obstructively jaundiced and remained so for
2 years, until September 1929. This jaun-
dice gradually assumed the greenish-bronze
type suggestive of malignancy at the head of
the pancreas, until he was reexplored by a
second surgeon (Dr. Pfeiffer) who found no
evidence of cancer of the pancreas or liver,
but the common bile-duct could not be iden-
tified in the mass of adhesions. The liver was
found enlarged with evidence of hepatitis and
cirrhosis. The pancreas was hard but not
greatly enlarged. Dr. Pfeiffer was able to
do a catheter anastomosis between the com-
mon hepatic duct and the duodenum, which
promptly established liver drainage and in 3
weeks jaundice had greatly decreased. A few
weeks later, following a grippal cold, he again
became jaundiced and remained so until seen
by me on April 4, 1930.
On physical examination he was found to
be intensely jaundiced in skin and scleras, of
the greenish-bronze type ; skin excoriated
from scratching; emaciated; arms wasted to
“broom sticks” ; weight 97 lb., representing
53 lb. below normal average ; temperature
range 97 J to 99.5°; pulse range 85 to 100;
blood pressure 120/85, despite pronounced ar-
teriosclerosis ; tongue heavily coated ; pyor-
rhea ; gingivitis ; sordes ; lungs relatively nor-
mal ; heart, diminished myocardial reserve.
Abdomen : retracted, scaphoid ; visible en-
largement of liver, palpable to 12 cm. below
808 JOURNAL OF THE MEDICAL
tip of ninth rib, with enlarged Riedel’s lobe
laterally ; both, right and left, lobes enlarged.
Over the mass of liver presenting below the
costal margin was a rounded, dome-like area,
somewhat roughened to palpation and quite
hard. The edge of the liver was more sharp
than rounded. Surprisingly few telangiectases
and few angiomas. No other abdominal
masses palpable. Spleen could be felt and
area of dulness was enlarged. There were
no varicose veins, and no ascites. Blood count :
Hemoglobin 68%; R. B. C., 3,610,000; color
index 0.9; W. B. C., 11,600; polymorphoneu-
trophils, 68 %. Blood chemistry, 5 examina-
tions: glucose 61, 66, 69, 69 and 68 mg.;
cholesterol 400. 376, 296 and 202 mg. Icterus
index 77, 54, 46, 33, 27.5; van den Bergh
direct delayed and biphasic reaction positive,
indirect reaction positive. Urinalysis: rela-
tively normal except faint traces of albumin ;
urobilinogen 1-160; Gmelin -j- 4; occasional
bile-stained pus cells.
On initial duodenal intubation, April 4,
1930, no bile was recovered, but after trans-
duodenal stimulations with hot water, normal
salt solution and magnesium sulphate, there
were recovered large quantities of whitish-
gray worm-like casts, apparently derived from
dilated intrahepatic bile-ducts. Many of these
were branched and varied in length 1-5 cm.;
along the edge could be detected a faint bile
tinge. Microscopically, these were demon-
strated to be muco-pus casts with enormous
numbers of polymorphonuclear leukocytes
and a high bacterial flora of bacilli and cocci
culturally identified as B. coli communis and
nonhemolytic streptococci. The total amount
of this material secured on first drainage
covered the bottom of an 8 oz. drainage bot-
tle to a height of 1)4 in. Following the re-
covery of these multiple casts, a small amount
of bile was secured, of a deep greenish-black
color, very thick, and containing much slimy,
flocculent material, microscopically showing
pus cells in abundance, much necrotic ma-
terial, and many broken down “shadow cells
of columnar epithelium slightly bile tinted.
As a result, it became evident that the anas-
tomosis between the common hepatic duct and
the duodenum was still patent, and the jaun-
dice was due to intrahepatic duct block.
SOCIETY OF NEW JERSEY Nov., 1931
He was admitted to Jefferson Hospital
April 7, where he was given short biliary
drainages every day or every second day, until
his discharge on May 2, and was also given
a vaccine of B. coli and streptococci. During
this time bile flow became fairly well estab-
lished; a total of 6490 mils (1)4 gal.) was re-
covered. This bile gradually decreased in
viscosity; the color improved from greenish-
black to greenish-yellow ; decreasing quanti-
ties of intrahepatic biliary casts were re-
covered, but large amounts of dense, slimy,
flocculent material, with pronounced oleagin-
ous degeneration but of a lighter yellow than
seen in cystic duct catarrh.
His drainages were continued at home at
intervals decreasing from twice a week to
once in 10 days. Altogether, several gallons
of bile were recovered. He had occasional
over-night drainages which yielded 1500 to
2000 mils each. This, however, apparently
decompressed the liver too rapidly and he
temporarily re jaundiced, so that weekly, short,
morning drainages appeared to be more ef-
fective. With this schedule he was gradually
becoming iess jaundiced and, as noted above,
his icterus index and blood chemistry im-
proved ; enlargement of the liver gradually
decreased and the surface became less dome-
shaped and irregular. He gained in strength,
in appetite and digestion, and increased 20 lb.
in weight.
Comment : Although the outlook for this
patient was still distinctly problematic, in view
of a badly damaged and structurally altered
liver, with probability of marked dilatation
of the intrahepatic ducts, the improvement se-
cured was encouraging. The problem was to
keep the duct system as clear as possible of
casts and flocculent material that otherwise
would obstruct bile flow and return him to
obstructive jaundice. Obviously, the anas-
tomosis between the hepatic duct and the duo-
denum was still patent. It is questionable
whether further surgical intervention could
improve the situation. Therefore, it was for-
tunate that duodenal tube drainage could be
helpful in his case. Although in cases of ob-
structive jaundice of shorter duration I have
many times recovered muco-pus casts of the
common bi-le duct alone, of the common bile
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
809
and pancreatic ducts, and of the common duct
and cystic duct, and numerous biliary thrombi
of the Naunyn type from the liver, this is
the first patient from whom I have recovered
casts from a dilated intrahepatic biliary tree,
proved by necropsy. I, therefore, consider
this case most exceptional.
He continued steadily to improve until the
last week of January 1931. when he caught
cold and shortly thereafter had a return of
the digestive upsets with abdominal pain ; con-
siderable chilliness and feverishness ; moder-
ate jaundice; considerable nausea; loss of ap-
petite and weight ; bowel movements did not
become acholic, and duodenal drainage at
weekly intervals was still quite free, but a
darker greenish-yellow with considerable
slimy sediment, without definite casts. From
this time on he began gradually to weaken
and became bedfast about February 20, with
evening chilliness, followed by rise of tem-
perature to 102° or 103° for a few hours and
then profuse perspiration. His last 2 drain-
ages on February 21 and 28 yielded respec-
tively 750 and 630 mils without need of
stimulation. His bowel movements remained
a dark yellow-brown up to the day before
death on March 4, 193 1 ; therefore, he ap-
peared to have no external hepatic block.
General interpretation of symptoms, in con-
sultation with Dr. Enoch, his family physi-
cian, on February 25, was as follows : Proba-
bility of acute suppurative hepatitis, not in
the sense of localized formed abscess but dif-
fuse hepatic abscesses not draining well into
internal hepatic tree ; probability of extensive
perihepatitis superimposed on biliary cirrho-
sis, and the clinical interpretation was con-
firmed by necropsy findings.
Case No. 649. Mr. L. J., referred by Dr.
L. F. Mulford, was 28 years old when first
seen October 1, 1919. He had a severe at-
tack of typhoid fever lasting 6 months when
10 years old ; since then, recurrent attacks of
mild jaundice. Fie was addicted to the fre-
quent use of calomel and other laxatives, to
control what he called “bilious attacks, con-
stipation, acne vulgaris and auto-intoxica-
tion”. In 1917 his appendix had been re-
moved to relieve this condition but proved in-
effectual. I had then been interested in bil-
iary tract drainage for about 2 years. Be-
tween 1920 and 1922 he was given a number
of 3 hour drainages, the results of which
failed to incriminate the gall-bladder. The
“B” fraction always appeared quite normal,
but the “C” fractions were turbid and con-
tained considerable flocculent material, micro-
scopically showing bile stained mucus, a few
pus cells and duct epithelium. He relapsed
so frequently into bilious attacks with slight
jaundice that he became discouraged and ask-
ed to have his gall-bladder removed. Yield-
ing to my curiosity to see what his gall-blad-
der would look like, the operative arrange-
ments were made. On February 22, 1922, at
operation by Drs. Despard and Mulford, the
gall-bladder appeared perfectly normal. The
liver edge and surface, as far as visible, was
everywhere finely scarred with connective tis-
sue infiltration in such a way that it resem-
bled the laminations seen when plate glass is
splintered along its edges. It was somewhat
enlarged and quite hard and in gross appear-
ance appeared cirrhotic. The head of the pan-
creas was enlarged and hardened. The sur-
geon removed the gall-bladder, which contain-
ed no stones, and microscopic sections were
normal.
It was agreed by the doctors present to tell
this patient nothing of the condition of his
liver so that he might receive as large psychic
benefit as possible from the removal of his
gall-bladder. He returned to New York and
was put on an orthodox text-book program of
management for cirrhosis of the liver, and
reported for follow-up examinations at in-
tervals of 6 months. In October 1924 (32
months after operation) there had been no
relief of his recurring sense of biliousness,
headaches, mild jaundice, and toxic disability
despite calomel every 2 weeks and a biliary
drainage about once a month. His liver had
gradually enlarged; he had lost about 20 lb.
in weight ; there was no ascites, but there were
pronounced telangiectases along the costal
margins, suggesting beginning portal obstruc-
tion. Fie seemed to be distinctly “slipping”.
He was then informed that he had cirrhosis
of the liver. I he orthodox management hav-
ing failed to give results, he was elected, with
810
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
his consent, as the first patient to undergo a
new and intensive plan of liver drainage by
duodenal tube. This, as stated, was designed
to emulate surgical choledochostomy in pa-
tients who had surgical unobstructed common
ducts.
He was admitted to a hospital as the first
experimental case, although he was reported
as Case II in the Jour. A. M. A., Vol. 85,
Nov. 14, 1925, in which this method was de-
scribed. In that paper you will find this re-
port: “From a man with cirrhosis of the liver
with sub- jaundice 2j4 years after cholecystec-
tomy, 19,760 mils (5 gallons) of bile mixture,
weighing 40 lb. (18 kg.) was recovered in 133
drainage hours, over an 18 day period, or at
the rate of 140 mils an hour, or 3360 for each
24 hours. His weight on admission was 121
lb. ; on discharge 123 lb. One year later he
was reported greatly improved, was no long-
er jaundiced and had gained 30 lb.”
I can now give an additional 5 years fol-
low-up on this patient. He has apparently
made a complete recovery, so far as can be
detected by clinical observation and laboratory
tests. He has never re-jaundiced; his liver has
returned to normal size, to palpation and per-
cussion ; has increased his weight gain an ad-
ditional 10 lb. ; digestion is entirely satisfac-
tory. He was last under observation during
October 1930.
The following case represents one of a
group of 11 patients featured by epiieptoid
convulsions and unconsciousness.
Case No. 2282. Mr. C. S. P., referred by
Dr. C. H. Arnold, of Ardmore, was 66 years
old when first seen October 22, 1929, com-
plaining of convulsive attacks followed bv un-
consciousness. When about 28 years of age
he was very active in athletics, and during
that time had frequent bilious attacks with
nausea and vomiting of dark greenish ma-
terial. His last attack of this character was
in 1890, after running a mile race. Although
he was never skin jaundiced during this early
period, since the beginning of his present ill-
ness he has had a tendency to light-colored
stools, approaching putty color, with urine the
color of strong tea, and transient jaundice.
Since January 18. 1924, he has had 19 ad-
ditional attacks; 2 in 1924; 2 in 1925; 3 in
1926; 3 in 1927; 3 in 1928; 6 in 1929. The in-
itial attack began at 6.30 a.m., when he fell in
the bathroom. In another attack during the
fore-noon he fell in a public place ; in a third
attack during the fore-noon he fell in his own
office. His family physician (Dr. Arnold)
had never witnessed an attack from beginning
to end, except a mild one in which the mus-
cles were in tonus and the jaws were grind-
ing. The patient’s wife, however, described
the attacks as a tonic stiffening of the muscles
of the body, chiefly the extremities, with the
hands moving upward to the head and the
arms partly crossed, legs extended and stiff-
ened, teeth clenched and tongue and lip of-
ten bitten ; no statement as to position of the
eyes or mouth frothing. The period of un-
consciousness is from 5 to 45 minutes. After
the convulsion he breaks out in dripping per-
spiration, the muscles gradually relax, con-
sciousness returns easily and quickly and he
becomes nauseated and vomits bile.
Until 1928 there was no premonitory aura
but since then he has noticed a peculiar sensa-
tion— like that of snuffing ammonia into the
nostrils — which gives him slight warning so
that he is often able to get to a chair, but he
has often fallen and hurt himself. The more
severe attacks have come on during the late
evening, or during the night or early morn-
ing, while in bed. He had been treated with
luminal ; potassium iodide ; calomel courses ;
oxycrystin; various intestinal antiseptics,
such as salol and urotropin ; some digestives,
such as elixir pept. enzyme, takadiastase, and
acidophilus preparations. Perhaps the most
important observation in this particular case
is a definite statement that from 3 to 7 days
before attacks his stools become light yel-
low to putty colored, his urine dark and con-
taining bile, and he has transient jaundice.
After routine clinical study, his diagnosis
was grouped as follows: Xo other ascertain-
able explanation of nature and cause of at-
tacks is as suggestive as hepatic-intestinal
toxemia; toxic subfunction of kidneys; gas-
tropancreatic subfunction; achylia vs. atrophic
gastritis ; arterial hypotension despite well
marked arteriosclerosis, focal infection in
tonsils and 1 tooth root. Hepatic function
tests: van den Bergh delayed direct reaction;
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
811
icterus index 11 (zone of latent jaundice).
Spence-Brett levulose test : Fasting blood
sugar 68 mg. per 100 c.c. ; 42 gm. levulose in
lemonade by mouth ; 30 minutes later, blood
sugar 111 mg. per 100 c.c.; 30 minutes later,
93 mg. ; 30 minutes later. 77 mg. Gastroin-
testinal x-ray study by Dr. W. F. Manges
summarized : “adhesions involving the gall-
bladder ; probable cholecystitis, to Graham
test ; stomach and duodenum normal ; numer-
ous diverticuli in transverse and descending
colons. Radiogram of skull : There is a polyp
in the right maxillary antrum ; the other ac-
cessory sinuses are clear ; bones of the skull
have normal thickness, perhaps slightly more
vascular than normal but the variation is not
sufficiently marked to warrant a positive diag-
nosis of lesion ; sella turcica is within normal ;
no positive x-ray evidence of lesion within the
skull. There is suggestion of sclerotic changes
in the right half of the pelvic bones.” Fie
was referred to Dr. D. J. McCarthy for a
neurologic study, and he reports : “After
reading your notes, supplemented by my
study, this case impresses me as one in which
the important factor is the influence of the
biliary and gastro-intestinal toxemia on a man
with an arteriosclerosis and whose brain and
circulation may, to a certain extent, be dis-
turbed by a kidney factor. The influence of
the focal factors, tonsils and teeth, on the
kidneys cannot be entirely disregarded. The
antral polyp may act as a reflex factor. I have
always considered the gastro-intestinal tract a
major factor in a large number of cases of
epilepsy. I think the intestinal factor may
act in several ways: (a) directly in the way
of toxic absorption; (b) reflex from stomach
by distension and disturbance of the circula-
tory mechanism; (c) both as a drag and re-
flex factor; (d) where associated factors,
such as liver and gall-bladder enter into the
situation.”
The keynote of his management has been
drainages of the biliary tract, of which he has
had 43 over a period of 19 months ; grad-
ually reduced from twice a week to once in
4 months. The amount of bile drainage se-
cured has been 9025 mils, or an average of
210 mils per drainage. Of this, 6055 mils
represented liver bile, or an average of 141
mils per drainage. This is a great contrast
to the amount of liver bile secured in normal
persons, or those ill with gastro-intestinal dif-
ficulties, other than hepatic torpor. Such pa-
tients in a 3 to 4 hours drainage session will
yield on an average 300 or more mils. This
suggests marked sluggishness on the part of
the secretory and excretory function of the
liver. This patient’s liver bile was unusually
turbid and of increased viscosity. There did
not appear to be infected bile, since repeated
cultures failed to grow out viable bacteria.
The microscopy of the bile was more sug-
gestive of catarrhal factors than inflamma-
tory. Abnormal amounts of lecithin were ob-
served. From this patient quite frequently a
peculiar milky white fluid has been obtained
from the duodenum, the nature and source of
which is not clear. The hepatic stimulative
effect of drainages was evident in increasing
the amount of liver bile recovered from early
averages of approximately 80 to a final aver-
age of 140 mils. However, even this latter
figure is only 2/3 that of normal.
Clinical results. This patient has had only
1 mild convulsion in a period of 19 months,
and it occurred when the interval between
drainages was lengthened out too abruptly.
In a group as small as this, one must learn by
individualization how frequently such extern-
al liver drainage must be done. Although a
good result in this case has been secured by
the intermittent plan of liver drainage, I am
of the opinion that in some cases 4 to 6 weeks
of intensive drainage might be better. In
none of the 11 patients has the Fay treat-
ment been employed unless it may be consid-
ered that bile drainage by means of magne-
sium sulphate brings about sufficient dehydra-
tion of itself. In 5 patients the use of luminal
was discarded entirely ; in 3 it was continued
in reduced doses for 2 to 3 months, although
its previous exhibition alone had been inef-
fectual.
Finally, there is a large group of patients
who give histories of atypical digestive symp-
toms, “dyspepsia”, “nervous indigestion”, and
“biliousness”, with anorexia, constipation,
headache, scotomas, nausea, belching, flatu-
lence, dizziness' or vertigo. They show var-
ious skin changes, sallowness, swarthiness,
812
JOURNAL OF THE MEDICAL SOCIE1 1 OF NEW JERSEY
Nov., 1931
petechia, “liver spots” ; and . telangiectases —
suggesting biliary or portal cirrhosis — but no
definite evidence in physical examination,
x-ray studies, or drainage findings, to condemn
the gall-bladder or appendix. In many pa-
tients of this group the gall-bladder and ap-
pendix have already been removed without
improvement. Many have disturbed sleep
states, are subject to nightmares or queer fan-
tastic dreams ; have involuntary muscular
twitchings ; painful cramps in lower leg mus-
cles ; foot cramp or toe cramp, the great toe
often pulling backward in spasm. Such patients
usually relate that they are utterly unrefresh-
ed in the morning, even after 10 or more
hours of heavy sleep, and awake feeling
“toxic” or “doped”. Some may have pro-
nounced fatigueability ; some are unaccount-
ably drowsy during the day, particularly after
meals. They are “chronically tired” ; “can’t
get enough sleep” ; “cannot concentrate” ;
they lose mental alertness ; speak of being
“mentally confused” and of “increasing for-
getfulness”, etc. Blondes develop gradually
increasing sallowness ; the, brunettes increased
pigmentation of skin or swarthiness. The
sclera is slightly jaundiced; stools often de-
ficient in bile ; urobilinogen index in the urine
is high. The outstanding clinical impression
in many of them is that they appear “toxic”.
What is the diagnosis in such patients? For
want of a better, I classify them as hepatic
toxemias ; as intestinal toxemias ; or, when
symptoms overlap conspicuously, hepatic-in-
testinal toxemias.
Sensible regulation of living; more fresh
air ; sunshine ; more exercise ; suitable dietet-
ics and particularly duodenal tube biliary
drainage, will secure much better results than
calomel, laxatives, purgatives or other drugs.
Formerly, colonic irrigations were a routine
part of the program, but in too many cases,
if too long continued, seemed to increase the
toxemia rather than improve it. An occa-
sional colonic irrigation may be useful, but
only in the beginning.
In many cases in this group spectacular im-
provement, in some brilliant cures, have been
brought about. If biliary drainage is omitted
from the above program the results are so
conspicuously less favorable that the patients,
familiar with its apparently detoxicating ef-
fect, will demand it. I do not mean to in-
fer that all patients so afflicted are cured. But,
at least, none of them are made worse, and in
those unimproved after an adequate trial, I
suspect that I have misdiagnosed them.
The following case is representative of this
group of 387 patients :
Case No. 1129. Miss E. M. R., aged 42, a
school teacher in New Jersey, was referred to
me on March 3, 1921. Aside from a severe
attack of typhoid fever complicated with
pneumonia, duration 4 months, 27 years pre-
viously, she had never been really ill. With
insidious onset about 5 years before (about
1917) and with steadily increasing intensity,
she gradually developed nausea, increasing
swarthiness and headache. She had vague
indigestion, but no clinical evidence of chole-
cystitis, appendicitis or colitis. She had been
a constant user of various “liver pills” al-
though she asserted that she had never been
troubled with constipation. I saw her infre-
quently between 1921 and 1925. She was
taught biliary drainage technic and took home-
drainages periodically. In February 1923, she
relates that a drainage every 2 weeks seemed
to hold her symptoms in check. If she went
over 4 weeks the attacks became severe. She
became, as she says, “top-heavy”, very dizzy,
extremely nauseated with napal And coronal
head pressure, “dancing specks” in eyes
(scotoma) and on several occasions has fal-
len to the floor or street with vertigo and mo-
mentary unconsciousness.
By July 1925, she stated that she had man-
aged to keep in a fair state of health only by
means of home drainages, which she said
“she could not possibly do without”. There
has been progressive tendency to the group
symptoms as mentioned above. She had be-
come more swarthy, with brownish pigment-
ed areas on cheeks and body ; icteric scleras ;
dried-out skin; 15 lb. loss in weight. Head-
aches occurred more frequently, several times
with explosions of severe prostration, exces-
sive dizziness, nausea and vomiting, van den
Bergh direct reaction negative; indirect re-
action 1.2 units or 2J4 times the normal.
Icterus index 17 ; levulose test — 50 gm. of
Nov;,, 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
813
levulose gives rising blood sugar curve and
temporary levulosuria.
It was evident that although biliary drain-
ages given every 2 weeks were of some bene-
fit they were not keeping pace with the in-
creasing toxemia. She was prevailed upon to
enter a hospital for 3 weeks of continuous
liver drainage. This yielded 10,935 mils of
bile mixture (2§4 gallons) weighing 45 lb. or
an average of 16.3 lb. per gallon. I have
found that the gallon of normal bile mixture
(representing, of course, some salivary, gas-
tric, duodenal and pancreatic fluid as well as
bile) weighs 6 or 7 lb. In cases such as the
above, the bile is unusually thick, of high vis-
cosity and contains a large amount of catar-
rhal flocculent material which greatly increases
its weight. It is usually turbid and drains
much more slowly because of its stringy vis-
cosity.
This patient’s admission weight was 124)4
lb., her discharge weight 129)4 lb. The clin-
ical evidence of detoxication was immediately
striking, but the important question was —
how long would it last? I have found that
in some cases such intensive courses of drain-
age may be required once every 1 or 2 years ;
in the majority of cases the more thorough
periods of drainage seem to yield, as in this
patient, better results, if followed by occa-
sional short morning or over-night drainages
4-6 times a year.
Her final report as of record February 2,
1931, shows that she has not lost a day’s work
in 4 years; has not required the services of a
doctor except reporting by letter or in person
about every 6 months ; has gained to her best
weight of 148 lb.
This is not an unusual case for I have many
patients from other states who are seen at in-
frequent intervals, dropping in to see me
when passing through Philadelphia, to tell me
they consider that use of the duodenal tube
“has saved their lives” or at least “made life
more bearable”. I dislike to use such phrases
but they are true; they reflect the attitude of
the patient and perhaps should be made a mat-
ter of record.
As useful as I believe non-surgical biliary
drainage (preferably called duodenal tube bil-
iary tract drainage) as applied to the selected
gall-bladder, I believe its greater field of use-
fulness is in the treatment of states of liver
disease or dysfunction. I believe the keynote
is the external drainage of toxic bile. But,
what are the toxins? We do not know, we can-
not as yet name them, weigh them or measure
them. Suitable methods for doing so have not
yet been introduced. Much further research
may be necessary, or the answer may come un-
expectedly from some quarter. My hypothesis
is that in such cases the liver has lost, in vary-
ing degree, its detoxifying ability or its bac-
teriacidal power, or both.
Since 1925, I have come to believe that
there is a better possibility of relieving deep-
seated organic pathology involving the liver
and bile ducts. Of course, structural changes
within the liver and ducts in chronic cases
may, and probably will, remain unaltered. But
it is conceivable that the progressive damage
that we have been led to expect may be re-
tarded or aborted if some part of the toxic
load is lifted from liver cells struggling to re-
gain their noteworthy margin of reserve. It
would appear that states of liver dysfunction
alone can be so improved as to make it less
likely that structural alteration will occur.
DISCUSSION
Dr. George Ii. Lathrope (Newark) ; The last
10 years has marked a very distinct advance in
the bulk of research concerning' liver functions,
and I think that a great deal of the stimulus to
such study has been derived from Dr. Lyon’s
work. To me that is the chief value of his work.
The question of therapy. I am going to leave
for others to discuss. The only thing that I want
to say, somewhat heretically, is that the duodenal
tube has been to me a very disappointing instru-
ment both from the standpoint of diagnosis and of
therapy.
In regard to the questions of liven function, I
want to make a couple of suggestions to the gen-
eral medical man, the general practitioner, who
gets hold of disturbances of physiology in their
early stages, long before they come to the labora-
tory and research hospital. If all medical men,
as they go about their daily rounds, would make
careful observations, careful notes, and at the
end of every 5 or 10 year’s period sit down and
study, and then turn in, the results of those ob-
servations, there would be a vast amount of fact
added to medical knowledge which is not now
available. The general practitioner rather dis-
regards his r61e as a research man.
There are 3 important liver functions — Dr. Lyon
mentioned 7, but I think the 3 really important
ones are: the glycogenic function, of which we
know a very fair amount; the biliary function,
of which we know a good deal; and the detoxicat-
ing or proteopexie function. It is an interesting
thing that of all the tests we have of liver function,
$14
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
about 8 out of 10 concern the biliary function. The
glucose tolerance test is a measurement of gly-
cogenesis. The hemoclastic crisis test is possibly a
test of the detoxicating function, but Dr. Lyon in-
dicated the fact that about this detoxicating func-
tion we know comparatively little.
One thing that I want to bring up is, that the
question of uric acid chemistry enters in. The
parenchyma of the liver is supplied by the portal
vein bringing blood from 2 sources; the mesenteric
bringing the end-products of digestion ; the splenic-
veins bringing blood from the general circulation.
Uric acid is probably brought into the liver from
both of those sources. We are prone to think of
food as the great source of uric acid bodies. Per-
sonally, I question that, especially in pathologic
conditions, for our own experience is that regula-
tion of diet has very little to do with regulating
a high blood uric acid. I think most of the bodies
which are brought from the intestinal tract to the
liver are, as a rule, fairly easily handled. As to
uric acid which comes from the body at large, in
chronic low graUe infections, we find the blood
uric acid increased in a certain proportion of
cases. Probably its source is the broken down
nuclei of white blood cells at the site of a focus of
infection, and we have come to feel that a high
blood uric acid is apt to be significant of a chronic
infection ; for we have reason* to believe that with
control of a chronic infection the amount of uric
acid in the blood decreases.
One other observation in regard to liver chem-
istry. This perhaps is a little bit sketchy but I
believe that in the study of achylia we shall learn
something about liver function. In pernicious
anemia we have, as a rule, sooner or later, a com-
plete achylia. We have long known that the use
of hydrochloric acid is a great help to pernicious
anemia patients, improving their digestion, and
improving their general condition. Since the use
of liver extract has come into vogue, with its as-
tonishing and dramatic improvement, if not cure,
of pernicious anemia, a good many observers have
said that they do not need to use hydrochloric
acid in conjunction with the eating of liver. We
always give both. This gave rise to a rather
curious observation not long ago. A patient had
come to us some 5 years back, age about 45, com-
plaining of diarrhea existing for 30 years or more
— loose bowels, not diarrhea; 4 to 5 loose stools a
day. He had no anemia; never had been anemic;
but he had a very marked gastric sub-acidity which
was evidenced by the fact that as soon as 30, 40,
or even 60 drops of dilute hydrochloric acid were
taken with his meals there was very considerable
improvement of his bowel condition. However,
that improvement was not a satisfactory one. He
would go along for 2 or 3 months fairly comfort-
ably, and then have a loose period again even
when taking the acid. Last November; talking this
thing over with him, I suggested, from a certain
analogy with the gastric condition in pernicious
anemia, that he take liver extract. He did so,
and I did not see him again until about 10 days
ago when he passed me on the street and shouted
out — “I haven’t had a bit of trouble since last
November.”
There is something there that needs to be cor-
related with the liver function ; that is, the ques-
tion of the gastric glands. We have clinically a
great many sub-acid states; meet them in our
hypothyroids, for instance, and we need a great
many observations, from all sorts of angles, to
find out where the liver comies into play in these
conditions.
Another interesting relationship of the stomach
to the liver concerns postoperative cases where
gall-bladders have been removed because of in-
fection, and following a period of apparent im-
provement comes a recurrence of symptoms, pain
and indigestion, toxic attacks, and cases of the
type that Dr. Lyon has described. Some of those
patients are very distinctly hypo-acid and a great
deal of their trouble is corrected by the mere ad-
dition of hydrochloric acid to their regimen. The
general practitioner must see a great many cases
of hepatitis, that is, enlargement of the liver as-
sociated with some mild or moderately severe sick-
ness, must see a great many more of those than
get to the hospital or the clinic, and his observa-
tions on these things should be recorded because
of their importance.
I have gone rather far afield in what I have
had to say but I want to say again that I think
we are very much indebted to Dr. Lyon for stirring
up interest in the general question of liver func-
tion.
Dr. A. E. Jaffin (Jersey City) : The remarks of
Drs. Lyon and Lathrope invite me to burden the
audience with a few clinical observations. T think
they both touched on recent experiences which
show that they are discussing from different angles
a functional disturbance, sometimes organic, known
to many and written about by some under the
heading of “'duodenal stasis”. While knowing very
little about the subject myself, a case in point is
worth citing.
A man who, in November, after grippe, con-
tinued feverish, developed mild jaundice with a
definitely high icteric index. Studies revealed
nothing organic besides a large liver and moder-
ate anemia. Fluoroscopic-ally, a very peculiar,
distended duodenum with reversed peristalsis was
observed, which at the timle was not given suffi-
cient credit as a factor in the symptomatology.
The length of the case, however, in its benign
course, began to throw out the various possibili-
ties of severe hepatic disease, malignancy and sup-
puration, and a re-check of the findings made it
appear that this man probably had, in connection
with an absence of free HC1., a biliary picture
which was very likely one of the types of cases
in which Dr. Lyon has had so much success.
While it is not possible for all practitioners to
have the same skill and facilities that Dr. Lyon
and his pupils have, a simpler method may, per-
haps, be used if you will give, in addition to acid,
a pint of warm saline in the morning. But I
think of far greater importance is study of the
disturbed physiology of the bowel, where it is not
organic, and the avoidance of errors in modes of
life and diet; the elimination of cathartics, and so
forth.
Dr. S. F. Wade (Elizabeth): Dr. Lyon, would
you add in your closing remarks your experience
with biliary drainage in toxic cases, in people of
40 years of age or more, who show a mild dia-
betic type controllable entirely by diet? Do you
get much help with the duodenal tube in such
cases ?
Dr. William A7. Barbarito (Jersey City): I would
like to ask Dr. Lyon if galactose and Ievulose tests
are of any importance in determining liver func-
tion? So far as I know, abroad these 2 tests are
considered very definite for destruction of the liver
parenchyma.
Dr. Maurice Asher (Newark): I would like to
add my mite to Dr. Lyon’s paper in reporting 3
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
815
cases of hepatitis, one of which was due to atophan
poisoning. Dr. Rabinowitz, of Brooklyn, in an A.
M. A. Journal of recent date, has reported a num-
ber of cases of cinchophen or atophan poisoning
in which the mortality was rather high. I haven’t
the data here but this patient was a young woman
who had taken a number of grains of atophan and
became jaundiced. I was rather alarmed over
her condition, because of the hig'h mortality in
such cases. Duodenal drainage promptly cleared
her up. I think she had about 7 drainages of 4
hours each, and she became perfectly well and
the jaundice disappeared. Then there were 2
other cases of hepatitis in elderly men with the
usual gastro-intestinal disturbance and with
jaundice and tenderness over the liver. The diag-
nosis of hepatitis was established. One man was
so ill that he came with the diagnosis of car-
cinoma, but our tests did not substantiate that
diagnosis. Both cases cleared up under biliary
drainage. The one with the supposed carcinoma
is entirely well and the other — still under treat-
ment— has improved and has returned to business.
Dr. Max Danzis (Newark) : Dr. Lyon mentioned
in his paper that a survey of a certain number
of patients submitted to cholecystectomy showed
the mortality was 10%; very high. In look-
ing over the statistics of many operators, not
necessarily the greatest surgeons in the world,
we find that the average mortality in cholecystec-
tomy is from 3 to 4%. In my own personal ex-
perience, with a large series of unselected cases,
the mortality is little over 3%.
Dr. Lyon speaks of patients previously operated
upon without any relief. There is a certain per-
centage of morbidity following cholecystectomy.
This is particularly true of patients who were oper-
ated upon for supposed gall-stones and at oper-
ation the only pathology found was either a thick-
ened gall-bladder or adhesions between the gall-
bladder and neighboring structures. The diagnosis
of cholecystitis is made at the operating table and
the gall-bladder removed. A percentage of these
patients yield the morbidity of which he spoke,
simply because there was some other pathology in
the abdomen which was overlooked at the time of
operation. In clear-cut cases of gall-bladder dis-
ease submitted to operation, the incidence of post-
operative morbidity is very small. My main con-
tention is this: If biliary drainage were definitely
standardized so that it could be applied scien-
tifically in properly selected cases, with definite
indications for that sort of treatment, and not be
made a means in the hands of a certain number
of men who use it as a panacea for all sorts of
gall-bladder or bile duct infections, then we could
probably understand each other a little better.
If those surgeons who have an extensive exper-
ience in gall-bladder surgery would tell their story,
citing incidents where biliary drainage was used
for a considerable time for all sorts of conditions,
such as gastric ulcers, clear-cut cases of gall-
stones, chronic appendicitis, obstructive jaundice
due to common duct stones or carcinoma, then the
tables would be turned the other way. As soon
as some doctors stop passing tubes into patients’
stomachs, irrespective as to what the indications
are, and confine their biliary drainage to those
rare cases where distinct benefit may be derived
from such treatment, this method will assume a
definite place as a therapeutic means for certain
medical conditions.
Dr. J. Polevski (Newark) : I should like to ask
Dr. Lyon his opinion upon a certain phase in the
dietary treatment in gall-bladder disease.
Physicians, generally, interdict the use of fat as
part of the diet as soon as a diagnosis of cho-
lecystitis is made. The idea, of course, is that fat,
as a great cholesterin producer, will, naturally,
favor formation of gall-stones.
What about the cholagogue action of fat ? It
has been pretty well established that a fatty meal
will cause emptying of the gall-bladder within 1
hour. Do we not serve ihe interest of the patient
best by allowing a fair amount of fat in the diet
in a case of cholecystitis. Of course, nobody will
think of allowing fat in the case of complete ob-
struction of bile flow in which case, because of the
absence of bile in the intestine, digestion of fat
will naturally be far from perfect, in fact, none
may take place, thus permitting non-split fat in
the stools, and irritation of the gastro-intestinal
tract.
There is another question which I have not been
able to settle in my own mind in all these years
that the Lyon-Meltzer method has been in vogue.
If we grant the tremendous bile draining power
of the fatty meal, why resort, for therapeutic pur-
poses, to use of the duodenal tube and magnesium
sulphate which is generally inserted twice weekly,
while the biliary drainage per via naturalis can
be resorted to by the patient 3 times a day without
any discomfort and rather with much relish to
himself? Also, has there been a comparative study
of the quantitative results of biliary drainage by
the 2 last mentioned methods?
Dr. B. B. Vincent Lyon : I was very much in-
terested in Dr. Lathrope’s discussion and I think
it is extremely timely, and his suggestion deserves
to be taken up by larger numbers of men in gen-
eral practice. I feel sure that they can, if they
will record and then publish their findings, add a
great deal to the efforts of men who are puzzling
themselves with research. The material at their
disposal is usually much less than is available in
general practice.
I am particularly interested in Dr. Lathrope’s
discussion of uric acid. I think that is quite per-
tinent. You will find in reported papers of Mann,
of the Mayo Clinic, on his experimental work on
animals, that he finds the liver, so far as he has
been able to judge it experimentally, is the only or-
gan capable of destroying uric acid. The liver is
also, to a large extent, the sole producer of urea.
Mann proposed a functional test of the liver in re-
gard to studying uric acid destruction that, so far
as I know, has not been taken advantage of by
any worker. I think Dr. Lathrope would be in-
terested in a paragraph or two in Mann’s papers
dealing with this subject.
Concerning what Dr. Lathrope said aboiit per-
nicious anemia, there is unquestionably some liver
deficiency. There is a tendency now to group per-
nicious anemia among the recognized deficiency
diseases. Despite the brilliant results from the
use of liver extract, most patients with grade 3
or 4 pernicious anemia have to continue the use
of liver extract indefinitely. Before liver extracts
came into vogue, we had been impressed by the
recovery of a number of pernicious anemics who
reestablished blood volume and count after duo-
denal tube liver drainage as spectacularly as
though they had had transfusions. We had col-
lected a number of records of that sort but when
the MurjDhy-Minot plan appeared, it seemed far
simpler to use liver extract rather than duodenal
tubes. I have a feeling, however, that if duodenal
tube drainage were combined with liver extract, it
816
JOURNAL OF THE MEDICAL SOCIETY -OF NEW JERSEY
Nov., 1931
might appear that somie cases that are now re-
lapsing after liver extract is withdrawn might
possibly have longer remissions. I would like to
leave that as a thought for those men who want
to work along that line.
This suggestion also serves as a connecting link
with thje second gentleman who discussed this
paper by asking a question in reference to dia-
betes. Beginning some 10 years ago, I have been
impressed by the large number of diabetics who
give an antecedent history of catarrhal jaundice.
That struck me as interesting because of the fact
that with obstructive jaundice in the large ma-
jority of cases the external pancreatic duct is ob-
structed as well as the common duct. That means
back pressure on both the liver and pancreatic
cells. I tried to imagine, in patients who sub-
sequently developed biabetes, that the intra-
pancreatic increased tension might conceivably
act more vigorously on the islands of Langerhans
than on other portions of the pancreas, and I took
the problem to Dr. Joslin, in Boston, with the ob-
ject of ascertaining whether antecedent catarrhal
jaundice was more frequent in diabetes than we
had been led to expect. Without going over his
records he was doubtful of my point of view, but
I asked him if he would send us a case of a young
diabetic whom he had been able to bring to the
highest point of health possible with his dietetic
method. He sent up a young gentleman and
whereas he was “spilling over” in the urine on a
1200 calories diet, we were able to carry him up to
a 2000 calories diet without glycosuria. The
hypothesis there ran along these lines: If in drain-
ing material from the duodenum, we are tapping
the liver, we are also recovering fluid from the
stomach, from the duodenum, and from the pan-
creas. Assuming that in this biliary mixture there
is a certain proportion of pancreatic external
secretion, we then must assume that we are re-
moving from the body a certain amount of amyl-
ase in each drainage. Could it be that by remov-
ing a certain amount of amylase there were less
amylase units left for the pancreas to use in the
conversion of carbohydrates into sugar? Was that
one reason why in some of these diabetic cases we
could further improve the clinical picture than
could be done exclusively by dietetics or the accus-
tomed diabetic management?
The next speaker referred to galactose and
levulose tests. I, personally, believe that they are
both important. I believe that, at the present
time, as Dr. Lathrope has already stated, there are
not enough tests to measure all of the functions of
the liver. But the modified Spence-Brett method
we have found more helpful because it eliminates
the renal threshold not accomplished by the
earlier levulose tests. The galactose method is
very well spoken of in Europe. Our experience
with it has not been as great as I would like but
at the present time we believe that the galactose
test does furnish some Information in regard to
the glycogenic function of the liver.
Dr. Danzis has requested me to furnish more
definite mortality statistics. I find that surgeons
are generally disturbed with the publication of
my own statistics and consider them abnormally
high. In 1923, I reviewed a series of 23,723 cases
of gall-bladder and biliary tract surgery. I ex-
cluded from consideration all series of cases that
were less than 200 and those appearing from
clinics which could not be considered Class A.
This I did in fairness to the surgeons, because it is
well known that the larger the series in unselected
cases and the higher the surgical skill, the lower
the mortality rate becomes. In the aggregate these
cases reviewed were collected from the published
reports of 6 European clinics which supplied 1939
such operations with a mortality average of 10.9%,
whereas 5 American clinics supplied 21,784 such
operative cases with an average mortality of
5.8%. This, therefore, represented a combined av-
erage for these 11 clinics of 8.35%. Furthermore,
it should be stated that 4 of the 5 American clinics
supplied 4804 cases with an average mortality of
6.69%, whereas the fifth American clinic alone
furnished 16,908 of such operative cases with a
mortality of only 2.6%. The nearly 17,000 cases
just mentioned will be found reported in a paper
by Dr. Mayo in the British Lancet of 1922 or 1923.
It gives one a profound impression of the enormous
number of cases this clinic has so capably han-
dled, due to developing master surgeons and good
team work. However, this series with its mor-
tality rate of only 2.6% and including all cases of
gall-tract disease from very early to very late
stages, covered a 30 year period from 1894 to 1923.
This attracted my attention, since the mortality
rate was so much lower than had been published
from other Class A clinics. I then turned to the
1924 volume of “Collected Papers of the Mayo
Clinics” to secure the statistics of the final year
of the 30 year period. They had done something
over 1200 cases in that 1 year with a mortality
rate of 2.5%. In other words, there was a differ-
ence of only 0.1% over a 30 year period, a large
part of it representing an experimental surgical
era in this subject, compared with their accom-
plishments in 1923. This seemed unusual. I then
turned to the Johns Hopkins Hospital reports over
the same length of time, from 1894 to 1923. By
comparison with the Mayo Clinic they had per-
formed an amazingly small number of biliary tract
operations. But over the same 30 year period the
mortality rate was 9%, whereas during 1923 they
had operated upon something over 200 patients
with less than 2% mortality. That seemed to me
much more consistent with statistical -expectancy.
Because I have been very greatly interested in
the surgery of this subject, I have made great effort
to select patients suitable for surgery and have
advised them to select thoroughly qualified sur-
geons. All of the cases I have reported have been
either operated on by master surgeons or unques-
tionably Class A surgeons. My own mortality
figures, nevertheless, have been as I stated, ap-
proximately 10% for primary operation. I am
quite satisfied that if all the surgeons throughout
the country who are now operating on biliary tract
disease as beginners, as junior apprentices, or
even as Class B surgeons, would publish their sta-
tistics, the mortality rates would be even higher
than they are now quoted. As some one truly
paraphrased it — “published statistics of themselves
do not lie, but the whole truth is concerned with
the statistics that are not published”.
In this connection, I do not wish to be miscon-
strued. I was trained under the influence of Dr.
John B. Deaver; I was a House Resident in his
hospital for 2% years. I have had opportunities
for contacts with very fine surgeons. I have ab-
solutely no quarrel with the surgeons, but rather
a high regard for their fine accomplishments. I
am simply stating my belief that despite the fact
that 10 years have elapsed the duodenal tube,
when properly used, is still under-rated as a very
useful part of the equipment of a doctor, whether
he is an internist or whether he is a surgeon. I
believe that if equal attention were paid to non-
operative technic, as is paid to operating room
technic, some of the abuses of the duodenal tube.
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
817
that I know to be taking' place, would be very
much less frequent.
The last doctor spoke about dietetics in gall-
bladder disease. I thought that in my paper I
had made my position plain. In Grades 2, 3, or 4
cholecystitis, where there is reason to believe that
the gall-bladder is definitely infected in its wall,
1 believe the gall-bladder should come out, and
should come out early, in order to save the liver
and other parts of the biliary tract system from
future damage. I am quite sure that there is
often too much procrastination on the part of the
physican. On the other hand, for patients In
whom a Graham test may show some moderate
disturbance in function and in whom duodenal tube
drainage study indicates that there is a Grade 1
or Grade 2 cholecystitis, undoubtedly dietetics
should be used. Here the fat -full meal should.be
favored because it is now well established that the
fat foods are the best physiologically normal
evacuators of the gall-bladder. My contention
is, that despite the readily accessible means
that we all have, external bile drainage is
of very great importance in the way of prevention
of later difficulties, if you will practice it in addi-
tion to the dietetics. Otherwise, you are draining,
let us say, a gall-bladder or a liver with a fat diet
and if there is loss of detoxifying power in the
liver, if there is loss in bacteriacidal power in the
liver, if there is an infection in the mucous mem-
brane of the gall-bladder, you are draining that
into the duodenal tract and into the intestinal
tract, when you might just as well drain it out-
side. It is not difficult.
In grade 3 or 4 cholecystitis with marked inflam-
mation, the objection to the fat-full diet is that it
provokes pain. I don’t mind throwing the patient
into a little pain in the interest of trying to get
him well if possible without surgery, but my feel-
ing is that if it throws him into pain it is a
surgical case and not one to be treated by either
duodenal tube or by fat-full diet. If there are
small stones in that gall-bladder, I then believe
that a fat-full diet is totally -wrong. It throws
too many of these patients into a biliary colic and
very often impacts a stone in the cystic duct that
makes the surgery much more difficult than if it
had been allowed to remain in the gall-bladder.
If the gall-bladder has been removed, fat-full foods
should be reduced. It does not require as much
fat under those conditions to give adequate stimu-
lation to the liver, and in those cases I use a fat-
reduced diet and usually a protein-low diet if the
urea nitrogen and the non-protein nitrogen in the
blood are elevated.
I very greatly hope that the position I have
taken will not be misconstrued. My argument
is this: There is a certain group of cases that is
definitely surgical and nothing else. There is
another group that is definitely medical, in my
judgment, and nothing else. In between, is a large
group that might fall one way or the other. I
think my personal experience has taught me that
patients who belong to the surgical type will go
through their operative procedure much better,
with much less immediate postoperative discom-
fort, if they are given a short period of prepara-
tion of the duodenum and of the liver before
operation by external bile drainage and all of the
internal cleansing that comes with flushing the
duodenum, sometimes with hypertonic solutions,
sometimes with others. It has taught me that
after an operation has been done it is bad practice
for the surgeon to say to his patient — “You can go
out and do about as you wish, with prudence: I
have cut out your disease, you can go ahead and
eat reasonably” — without any further postopera-
tive advice to the patient, and without himself
knowing what smoldering- infection is left behind
in the liver or ducts. In most instances he has
not “cut out the disease”, but has wisely taken
the first step, which should then be followed up
by more adequate postoperative care. The case
reports in this paper should indicate the wisdom
of a change in our methods.
Finally, I believe it should be the responsible
duty of the surgeon, within 6 to 10 weeks after
such a cholecystectomy, to see that a possible
residual hepatitis or cholangeitis is properly ap-
praised by the duodenal tube. If you find ab-
normal bile drainage from the liver or ducts, if you
find abnormal microscopy, if you find abnormal
bacteriology, that is the time to take steps to pre-
vent a postoperative relapse, instead of waiting
until the patient comes back complaining, with
symptoms of still existent liver disease. I
should think that the surgeons would find it of
very great advantage to themselves to properly
add to their surgical machinery a qualified man
on their own staff or get in liaison with a prop-
erly qualified member of the medical staff to de-
velop that kind of team work. That is all the —
I don’t like to use the word— -“quarrel” that I
have with the surgeons. I do not misunderstand
them, and I am trying to make my own position
as clear as I can.
NEW METHOD OF OUTLINING THE
HEART, ITS CHAMBERS AND
GREAT VESSELS
Clyde M. Fish, M.D.,
Medical Director Atlantic C ounty Hospital for
Tuberculous Diseases, and Chief of Tuberculosis
Clinic, Atlantic City Hospital
Atlantic City, N. J.
The purpose of this paper is to present the
technic of a method of auscultatory percussion
by which it is possible to outline definitely and
with marked exactitude, the heart, the heart
cavities, the aortic arch and the great vessels,
and to call attention to the wide usefulness of
this method in the conduct -of a physical ex-
amination.
The pioneer in mediate percussion was Pi-
orry, of Poitiers, France, who was also the
inventor of the pleximeter. but ever since
Auenbr ugger’s work was reversed by Cor-
visart, in 1808, percussion has been an im-
portant adjunct to methods of physical ex-
amination. Not until modern times, how-
ever, did percussion become a diagnostic pro-
cedure, and it was to enhance such use and
to demonstrate its value that the procedure
here to be outlined was evolved. Its novelty
818
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
does not depend upon the use of auscultatory
percussion but upon the manner in which this
procedure is utilized and interpreted, for an
understanding of which some preliminary dis-
cussion of the principles underlying percus-
sion is necessary.
The literature concerning percussion as a
means of physical diagnosis is astonishingly
restricted and it would seem that those who
have studied it in the past had decided that
no further possibilities of development ex-
isted. There is a tendency, therefore, to re-
gard it as a procedure of limited value to the
diagnostician. The underlying principles of
auscultatory percussion may be summarized
as follows: The problem is one of sound
transmission and, whether applied to animate
or inanimate structures, there are certain fund-
amental laws which always hold true. In the
first place, the ease with which sound travels
through different mediums varies necessarily
with the variations in density and elasticity of
the medium. A stroke of given force, which
gives rise to audible vibrations in a medium
of one density, will fail to produce audible
vibrations in a medium of lesser density. Gas,
for example, conducts sound far less readily
than liquid, and a porous medium composed
of solid and gas will not conduct sound as
readily as a medium composed of solid and
liquid.
In the second place, if sound is produced
over a medium of a certain density and elas-
ticity, it will be more readily conducted
through that medium than through one
of a different density and elasticity,
even though the 2 mediums are in apposi-
tion. Application of these principles makes
it possible to map out, by auscultatory per-
cussion, the size, shape and position of the
heart with its great vessels, and also the cham-
bers within the heart. The density of the
heart is such that a very light stroke, the bell
of the stethoscope being over some portion of
the organ, gives rise to audible vibrations ;
while, owing to its lesser density, the vibra-
tions in the adjacent lung are not audible.
These facts make it possible so to gauge the
percussion stroke by any pleximeter (finger or
instrument) that the first audible vibrations
are heard when the pleximeter reaches the
border of the heart.
Because of the second principle above
stated, it is possible, by placing the hell of the
stethoscope over various points on the heart
and great vessels, to map out not only the
borders of the heart and great vessels but also
the borders of the chambers within the heart.
It is necessary, of course, to vary the force of
the percussion stroke in accordance with the
depth of the structure to be outlined.
'the exact technic: In outlining the borders
of the heart, cardiac chambers and great ves-
sels, I use the Ford stethoscope and have
found that more accurate results are obtained
in outlining the more superficial structures by
substituting a piece of. rubber tubing for the
bell of the stethoscope. In this outline of the
technic I shall, therefore, specify the points
where the bell of the stethoscope is most satis-
factory and those where the rubber tubing is
used to best advantage.
The hell of the stethoscope is first placed
just helow the tip of the xiphoid process and
to the right of the midline (Point 1 on the dia-
gram). Then, beginning on the lower thoracic
wall and percussing from the sides toward the
sternum, using a gentle percussion stroke, a
definite increase in volume of sound is heard
when the percussing finger reaches a point
which corresponds to the surface markings of
the inferior vena cava. The course of this
vessel can be followed to a point beneath the
right border of the sternum at the level of
the third interspace, at which point the vena
cava enters the right auricle.
Then, substituting a piece of r4 in. rubber
tubing for the bell of the stethoscope, and plac-
ing the tubing at point 2 on the diagram (the
right border of the sternum at the level of
the third interspace), and using a very gentle
percussion stroke, it is possible to percuss out
2 areas which correspond to the right auricle
and right ventricle. Owing to greater depth
of the ventricle, it is necessary to use a some-
what heavier stroke when percussing its
borders. When the percussion stroke is prop-
erly gauged, a very definite increase in the
volume of sound is heard as the borders of
the cardiac chambers are reached.
The tubing of the stethoscope is again sub-
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
819
stituted for the bell and moved to point 3 on
the diagram (the third interspace just to the
left of the sternum). From this point, by the
same method used in outlining the borders of
the right auricle and ventricle, it is possible to
outline the left auricle and ventricle, keeping
in mind the fact that a heavier percussion
stroke is necessary in outlining a deeper struc-
ture, than a more superficial one.
Without changing the point of contact for
the stethoscope, but using the bell instead of
the tubing, the ascending, transverse and de-
scending rami of the arch of the aorta may
be outlined, as shown in the diagram. If the
stethoscope bell is then placed at point 4 on
the diagram (below the xiphoid process and
just to the left of the midline), the descending
aorta may be traced from below upward; and
this is found to coincide accurately with the
descending limb of the arch as determined
from point 3. As that point overlies the in-
terventricular septum, the outer borders of
the heart can be outlined by the same technic.
The cardiac chambers previously outlined are
found to lie within these borders.
I do not presume to state that the outline
of structures obtained by this technic corres-
ponds absolutely with the true anatomic out-
line of the underlying structures. There is
bound to be a certain amorftit of distortion
caused by differences in structure of tissues
lying between the bell of the stethoscope and
the structure which is being outlined. Also, it
must be borne in mind that sound travels out-
ward in all directions and there will, there-
fore, be more or less magnification of the size
of underlying structures, varying with the
depth of the structure whose outline is being
determined. A deeper structure will give a
larger outline by both auscultatory and medi-
ate percussion than a structure of equal size
which is more superficially situated. However,
inasmuch as the findings have not only been
constant, but have been repeatedly checked
by postmortem and x-ray pictures, I feel
certain that a definite ratio can be established
between the size and contour of underlying
structures and their surface outlines, as ob-
tained by auscultatory percussion.
The present communication concerns the
method itself, its technic and its application to
study of the cardiovascular system of the nor-
mal individual. Its application to other vis-
cera and to abnormal conditions will be pre-
sented in a future communication in which its
value and accuracy have been demonstrated in
such conditions as aortic aneurysm, medias-
tinal tumors, dilatation of the cardiac cham-
bers, and, in fact, in any condition in which
the normal contour of viscera is disturbed.
UTERINE HEMORRHAGES RADIO-
LOGICALLY CONSIDERED*
W. G. Herrman, M.D., F.A.C.P.,
Asbury Park, N. J.
Surgeons, internists and radiologists are
frequently consulted by or concerning patients
suffering from uterine hemorrhage. One may
meet such a problem in his office or in a hos-
pital. A great majority of those present this
evening have seen such patients recently or
may tomorrow. I have been frequently asked
to give an opinion as to whether this or that
patient would be benefited by radiation. I
have been stopped in the hospital corridor ;
symptoms have been related to me rapidly, and
I was expected to say “yes” or “no”. De-
cision as to how such patients should be treat-
ed ought not be reached so hurriedly by any
of us. Uterine hemorrhage is a condition
which, in the vast majority of instances, can
be corrected, but the measure to be adopted
should be determined always upon the basis
of conditions existing in the particular case
under observation and that can only be de-
cided after careful examination. Sometimes
the examination must include not only the
history taking and bimanual physical exami-
nation, but also certain laboratory and even
x-ray studies ; and the x-ray studies may in-
clude injection of the uterus with lipiodol and
performance of pneumoperitoneum, so that
presence or absence of adnexal pathology can
be determined without opening the abdomen.
All will agree that no treatment should be in-
stituted, for any condition, without as thor-
*(Read before the Monmouth County Medical
Society, April 29, 1931.)
820
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
ough an examination as possible, and yet we
are all prone, in some cases at least, to ignore
this desideratum in the concrete while agree-
ing to it in the abstract. I have, for example,
found fairly well advanced carcinoma of the
cervix in a number of women who had been
under medical supervision for months, the su-
pervision being that of men I have considered
competent, and still do, but who in the par-
ticular case in question had not made a pel-
vic examination. They have not been ignor-
ant, since invariably the reply to my question,
as to whether the patient has had a vaginal
examination, has been in the negative. If they
had made even the most cursory vaginal ex-
amination they would have detected the true
cause of the hemorrhage.
For the purposes of this paper, I shall di-
vide our patients into age periods, such as, 15
to 30, 30 to 50, and over 50. Certain patho-
logic conditions which give rise to uterine
hemorrhage are more common in some age
periods than in others. In the first age period,
from 15 to 30, while cancer is not unknown
and, apparently, is now being seen more fre-
quently than ever before, we shall for the
moment defer its discussion. We shall, there-
fore, first consider ovarian dysfunction,
chronic endometritis, anemia, constitutional
dyscrasia, glandular distrophy and pelvic in-
flammation. All of the conditions mentioned,
except ovarian dysfunction, chronic endome-
tritis and pelvic inflammation, are exclusively
in the field of the internist, and should be
passed upon by him before the patient con-
sults a surgeon or radiologist.
Among systemic conditions that may under-
lie excessive menstruation are hemorrhagic
diathesis, scurvy, malaria, lead poisoning and
acute infectious diseases such as scarlet fever,
diphtheria and typhoid. Menorrhagia asso-
ciated with such causes is often difficult to
treat because, as Croon says, they interact in
such a way as to form a vicious circle. Chron-
ic mental depression, hysteria, sedentary hab-
its and residence in high altitudes or in the
tropics, dispose to menorrhagia. In some
cases anemia, although usually a cause of
amenorrhea, may induce uterine hemorrhage ;
explained by low specific gravity and dimin-
ished coagulability of the blood. Pelvic ex-
amination, made if necessary under anesthesia
in young women, should be employed to ex-
clude malposition of the uterus, ovarian cysts,
and pelvic inflammations like ovaritis, salpin-
gitis, parametritis and perimetritis. Ovarian
dysfunction and chronic endometritis are often
treated by curettage, and many such patients
have return of symptoms in from 1 to 3
months. The same is also true of uterine
myomas, where if a small amount of radium,
properlv filtered, had been inserted immediate-
ly after the curettage, and left sufficiently long
to give a dose of 200-500 mgm. hours, a much
greater percentage of cure might have been
obtained. The ovaries when so treated are
only temporarily affected; amenorrhea being
present generally for only a few months fol-
lowing treatment ; but even this short period
of rest and non-function often enables nature
to establish a normal cycle in cases of dysfunc-
tion, while in cases of chronic endometritis
with hypertrophic endometrium the over-pro-
liferation of cells is stopped. Roentgen ray
therapy is not so well adapted as radium in
the treatment of chronic endometritis, inas-
much as a far greater dosage to the pelvis is
necessary in order that sufficient radiation
may be given to Hie hemorrhagic endometrium.
Some investigators report excellent results in
the treatment of dysfunction, or painful and
prolonged menstruation, from small doses of
x-rays over the ovaries.
In the age period from 30 to 50, we have
to consider principally uterine fibromyomas,
myopathic premenopausal hemorrhage, and
cancer of the cervix or body of the
uterus. The proper treatment of fibromyoma
has long been a subject of controversy be-
tween those advocating surgical procedure and
those advising some form of radiation ; a con-
troversy that reminds me of the fable of “the
bull-dog on the banks and the bull-frog in the
pool”. There are enough of these patients
and enough variation in case histories to satis-
fy every one concerned, and the subject should
be properly studied for classification so that
each patient shall receive the best treatment
for her particular condition. In women un-
der 40 years of age, particularly those who
Nov., 1031
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
821
are still in the childbearing period, where the
fibroid does not involve the entire uterus and
there is possibility of saving the uterus for its
normal purposes, a myomectomy should be
performed. In any case, where there is pel-
vic inflammation or other gynecologic compli-
cation, radiation should be avoided ; because
latent pelvic sepsis may be lighted up. How-
ever, recent developments require qualifica-
tion of the last statement, in that some chron-
ic pus-tubes have benefited from application
of x-rays in small doses, and ovarian cysts
have been known to degenerate as the result
of such radiation. The statement has been
made that because of the possibility of ovarian
cysts or other adnexal complications being
present but not recognized, surgical treatment
is to be preferred in every case of fibromyoma.
So far as cysts are concerned, if the usual
physical examination cannot definitely rule
out their presence, we have today a combined
lipiodol and pneumoperitoneum x-ray exami-
nation which can be depended upon to settle
that question. So far as concerns infection
which cannot be recognized clinically, Dr.
Francis Carter Wood states : “In a series
of 150 fibromyomas recorded at St. Luke’s
Hospital, evidence of chronic process was
found in only 41 ; no example of an acute pro-
cess was seen in any ; and such chronic pro-
cesses of low degree, as are only found micro-
scopically, are frequently associated with small
cysts of the ovaries, but said lesions do not
give rise to symptoms that justify laparot-
omy.” The statement is often made that sur-
gery is the better treatment for all fibromy-
omas because cancer of the fundus may com-
plicate any given case, and if such a patient is
treated first by radiation valuable time will be
lost. The frequency of such a complication
in the cases reviewed by Wood is 0.5%. If
to these cases of fundus cancer we add cases
of sarcomatous degeneration of a fibroid, we
will have a little more than 1% of the total
number of fibroids considered, but that per-
centage of malignant fundal involvement, if
allowed to go unrecognized to a fatal end,
would still be less than the minimal operative
mortality, which is 1.5%. However, a num-
ber of these cases will be detected in time even
if radiation therapy is tried. If intra-uterine
radium treatment is to be given, curettage
should be done before insertion of the radium,
as that procedure will enable us to detect some
of the cancerous conditions. If hemorrhage
continues after a few x-ray treatments, the
therapist should suspect a complicating lesion,
because, as a rule, unless there is considerable
anemia or other blood dyscrasia, hemorrhage
should be checked fairly early in the treat-
ment. Surgeons have also contended that in
young women complete removal of the uterus
but leaving the ovaries intact is better therapy
than radiation because ovarian hormones are
retained. Some investigators report that
in about 2 years after hysterectomy the ova-
ries cease to function and thus an artificial
menopause results anyway. The menopause
following radiation is seldom severe and might
just as well take place at the time of treat-
ment as 2 years later.
An intramural fibroid not larger than a 3
months’ pregnancy is the ideal type for radia-
tion therapy, and the patient is generally in
better health subsequent to radiation than
after an operation. Steinach, as you know,
has advocated x-ray therapy for the ovaries
as a method of rejuvenation comparable to
that following ligation of the vas deferens in
the male. I can personally state that a num-
ber of women have, after radiation therapy
for either fibromyoma or carcinoma, reported
a renewed sense of well-being which made
them feel “years younger”, and in many in-
stances their general appearance has borne
out the statement. Many women with fibro-
myomas have cardiac changes or cardiorenal
disease which would increase the mortality
rate if surgical measures were used; so, such
patients, at least, should be sent for radiation
therapy. Pedunculated, markedly irregular
fibroid, or very large ones, are not ideal con-
ditions for radiation, but even in such cases,
when operation is contraindicated, radiation
should be resorted to rather than risk life in
a hysterectomy. Large, hard or necrotic fib-
roids, or those that are calcified, will not, of
course, yield to radiation and should be re-
moved surgically.
We consider Roentgen ray therapy prefer-
able in ambulatory cases and for women who
are thin or below average size. Radium
822
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
should be used on the obese, or for those ac-
tively hemorrhaging. In order to reach the
uterus and ovaries in the obese patient, the tis-.*
sues anterior and posterior to those organsi
must he radiated considerably, and it is pos-
sible to produce skin changes of the abdominal
wall before sufficient radiation reaches the
ovaries and uterus. As a rule, radium effect
is noticed more quickly than that of x-rays
and the accompanying curettage and packing
will also help to stop bleeding. Sometimes the
use of radium and x-rays together is neces-
sary, as was done in some of my cases where
the uterine canal was short and most of tne
radium was placed only in the cervix, where
it was sufficient to stop immediate bleeding
but a co-ridete result was not obtained until
further x-ray treatments were given. Where
radium is used, a diagnostic curettage is pos-
sible and desirable so as to exclude fundal
cancer, a condition which is not, as a rule,
amenable to radiation and which is 80% cur-
able by operation, while still confined to the
corpus uteri. Some radiologists believe that
even where patients are referred for Roent-
gen ray treatment of fibroids there should be a
diagnostic curettage first. This is not entire-
ly necessary, as we have already stated, be-
cause: (1) only a very small percentage of
fibroids are complicated by cancer; (2) this
condition does not advance particularly rap-
idly; and (3) it can be diagnosed fairly well
by lack of response to Roentgen ray treat-
ment; in other words, if the usual treatment
for fibromyoma does not stop the hemorrhage,
a fundal cancer is probably present. In
properly selected cases, patients should be en-
tirely relieved, safely and without hospital-
ization, loss of time, or impairment of the
body as a whole, by x-ray therapy.
The same relief of symptoms can be ob-
tained in the myopathic hemorrhage case with
premenopausal symptoms, including psycho-
sis, nervous and neurotic symptoms such as
headache or nausea, by causing a complete
menopause, and this without shock or hos-
pitalization. There are certain other cases
where an artificial menopause to stop uterine
bleeding may be therapeutically indicated,
where the uterine bleeding per se is not of any
great moment ; as in cases of anemia, marked-
ly prolonged clotting time, and as in a recent
case where the uterine bleeding was not much
above normal but the patient had also an ul-
cerative colitis producing at every menstrual
period rathei severe bleeding from the rectum.
This patient has been given an artificial meno-
pause without risk to her general health, with
complete cessation of uterine bleeding, and
with very infrequent and very slight rectal
bleeding. There is another condition which
may cause uterine hemorrhage duriug the
child-bearing period and that is the formation
of uterine moles, either the so-called fleshy
mole or hydatidiform mole. Either condition
is accompanied by some of the signs of preg-
nancy, rapid increase in size of the uterus to-
gether with hemorrhage, and by expulsion of
characteristic material. These conditions
should, of course, be ruled out before recom-
mending radiation therapy.
We have now come to the subject of can-
cer of the cervix and of the fundus uteri.
These conditions are frequently found in the
age period between 30 and 50, of course, but
more commonly near the upper limits of this
period and after 50, where they are the most
common cause of uterine bleeding. Concern-
ing cancer of the cervix, the view is now wide-
ly held, and is approved by the American Col-
lege of Surgeons, that radiation can accom-
plish all that surgery would in the first stage
and more than surgery can in the other stages.
Most cancers of the cervix are epidermoid in
type ; which accounts for the large percentage
of favorable reactions to radiation. The ad-
enoma type of cancer is often quite resistant.
It is rather fortunate that the more malig-
nant types, here as elsewhere, are radio-sensi-
tive. Cancer of the cervix is best treated by
the combined method; i.e. radium within the
cervix and uterus, followed by high voltage,
heavily filtered x-rays externally. When can-
cer of the cervix is to he treated surgically,
only the most radical form of surgical pro-
cedure should be considered ; and this would
certainly be termed a major operatio)i both
from the standpoint of the risk involved and
the financial outlay necessary. Modern tech-
nic calls for considerable attention by the ra-
diation therapist in addition to the insertion
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
823
of elementary radium. Interstitial radiation
by gold implants may be necessary and these
are in themselves quite costly, and high volt-
age therapy should always follow the radium
treatment if at all possible. These various
treatments take time and require the use of
expensive equipment, to say nothing of the
skill required. Interstitial radiation is es-
pecially expensive for a person of moderate
means, in a small community, and often the
cost of gold implants is as much as a mod-
erate operation fee. Fortunately, unlike can-
cer in other parts of the body, cancer of the
cervix, in the first and often in the second
stage, can many times be absolutely eradicated
by proper radiation therapy.
Cancer of the fundus of the uterus is al-
ways a surgical disease. Radiation helps but
little, and since, fortunately, fundus cancer
may exist for some time without metastasis,
an absolute cure can often be obtained by hys-
terectomy. The question is sometimes raised
as to whether the operation should be a supra-
vaginal or a complete hysterectomy. If the
cervix is to be left, it should not be ignored.
I have treated several patients for cancer of
the cervix which developed subsequent to su-
pravaginal hysterectomy. If the cervix is to
be left because supravaginal hysterectomy is
an easier surgical procedure, is less shock to
the patient, and leaves a better anatomic floor
to the pelvis ; then, I believe that the cervix
should be radiated either before or after op-
eration, and whether or not it is radiated the
patient should be instructed to return at in-
tervals for examination for possible cancer-
ous involvement just as though she had not
had an operation.
Resume
The purpose of this paper has been to draw
attention to the fact that a great many uterine
hemorrhages are amenable to radiation ; many
of them without hospitalization and without
any operative procedure at all. It is not nec-
essary to avoid radiation therapy nowadays,
for fear that some intrapelvic pathology may
be overlooked clinically that would be recog-
nized at the time of a laparotomy. For be-
nign uterine bleeding in patients around the
menopause age, not complicated by cysts or
acute infectious processes, radiation is the
method of choice, by reason of low mortality
incident thereto, because the patient can re-
main ambulatory, and because, as a rule, the
expenses incident thereto are less than com-
bined hospital and surgical fees. Complica-
tions that cannot be recognized clinically are
not very frequent.
Where constitutional conditions make op-
eration hazardous, radiation therapy is the
first consideration, even with large or irreg-
ular, pedunculated tumors.
In young women, where myomectomy is
possible, radiation is contraindicated. Where
hysterectomy is necessary, radiation is of
equal value, and Wood says we do not need
to fear malignant degeneration. In cervical
cancer radiation therapy is at all stages pref-
erable, and generally the cervix should not be
removed. Where fundal cancer is diagnosed
or suspected, hysterectomy is indicated.
It should be recognized by surgeons, in-
ternists and radiologists that there are many
cases of uterine hemorrhage with other than
local causes, and that the highest percentage of
good results will be obtained where the patient
has a thorough clinical study before any
method of treatment is adopted, and where
there is a friendly sort of discussion and con-
sultation among the medical advisers before
any line of therapy is adopted.
CARDIAC FAILURE OF THE CON-
GESTIVE TYPE
Charles E. Teeter, M.D., F.A.C.P.,
Newark, N. [.
Increase in the cardiac death rate has oc-
casioned grave concern in medical circles. The
possible causes of this increase may be the
lengthened span of human life; strain of our
modern complex living, with its frequent
emotional upsets ; the more careful keeping
of records ; or, perhaps it may be due to an
actual increase in diseases of the heart. Any
consideration, therefore, of cardiac failure, its
causes, and plans for relief when it has oc-
curred, becomes to each of us matter for care-
824
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
ful study. It is to be hoped that in the dis-
cussion which may follow reading of these
papers, some facts will be developed which
may he helpful and encouraging to those
of us who have to do with the care of these
distressing and difficult cases.
Naturally, there are 2 questions which arise
in a discussion of this type: (1) just what is
cardiac failure; (2) what are its causes?
Cardiac failure is well described by Mack-
enzie as “a condition in which the heart is
unable to maintain an efficient circulation,
when called upon to meet the efforts neces-
sary to the daily life of the individual”. What
are the causes of cardiac failure, is a question
which has not been adequately answered. It
is very difficult, indeed, to understand why, in
rheumatic disease of the heart and in hyper-
tensive heart disease, an efficient circulation
can be maintained for so long a period with-
out evidence of failure and then, with no ap-
parent change ir. the lesion present, nor alter-
ation in the rhythm or change in elevation of
the blood pressure, cardiac failure begins and
progresses to a fatal termination. In obstruc-
tive lesions of the coronary artery, with an
area of local death in the heart wall, inability
of the heart to maintain an efficient circula-
tion can be more easily understood. Where
failure occurs without any change in the ana-
tomic lesion present, manifestly, it must re-
sult from disturbed function, and the most
common disturbance of function causing fail-
ure is, in my opinion, fatigue. This is illus-
trated by a patient seen in 1929. A strong, ro-
bust girl of 15 years, weighing 135 lb., was
suddenly seized with an attack of rapid heart,
and a ventricular rate of 230. There was no
rheumatic history other than that she had fre-
quent attacks of tonsillitis. Pressure on the
vagus in the neck, or pressure on the eyeballs,
produced no change in the rate; there was no
arhythmia. The electrocardiogram showed
tachycardia of unknown origin. There was
no fever. This high pulse rate was kept up
day and night, continuously, for a period of
4 weeks, at the end of which time the patient
began to show symptoms of congestive failure,
i.e. edema of the extremities, engorgement of
the veins in the neck, enlargement of the liver
and albumin in her urine. The heart rate then
suddenly returned to normal. With this sud-
den fall of rate and consequent slowing of the
circulation, she developed a thrombophlebitis
of the veins in her left arm, with edema. The
next day there occurred a right hemiplegia,
probably as the result of a thrombus in the
left auricular appendix. She eventually made
a complete recovery. The point in the story
is, that it took 4 weeks of this extreme rate
before fatigue was sufficient to cause begin-
ning failure.
Again, a doctor recently seen, aged 58, gave
a history that for 20 years he had experienced
attacks of rapid heart beginning suddenly and
terminating abruptly ; the rhythm was always
irregular (fibrillation), rate 140; attacks were
always of short duration and inconvenienced
him very little; he would go about his work
and in a short while recover. One day he had
an attack which continued 4 days, when conges-
tive failure began, and before the day ended
was very severe ; he could not lie down ; edema
of the extremities was present ; cyanosis ; en-
largement of the liver; rales in his chest: al-
bumin and casts in his urine. Fortunately,
during the night his heart rate suddenly re-
turned to normal, and all symptoms rapidly
cleared up.
In the first case, of a young individual, it
took 4 weeks to wear the heart down, while
in the second case, an older person, it took
only 4 days.
Just what occurs in the heart muscle, the
seat of fatigue, has not as yet been deter-
mined. Gellhorn’s recent work on muscle
fatigue attributes it to a loss of calcium in
the muscle substance. In some experiments
he has abolished muscle fatigue, at least tem-
porarily, by giving calcium chloride. Other
biochemists believe that fatigue is due to a
loss of potassium, and still others believe it
due to depletion of glycogen in the muscle. It
has been proved that the giving of potassium
will relieve the heart in failure for a period,
and we all know that intravenous injection of
glucose will often help, when all other cardiac
measures have failed, in a patient with con-
gestive failure. Again, it is well known that
in cases of diabetes where the blood sugar is
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
825
high, much harm can be done to the heart
when the blood sugar is reduced too low by
insulin.
The secondary causes of cardiac failure are
many. They may be divided into 2 classes,
intrinsic and extrinsic.
Intrinsic : ( 1 ) Advancing rheumatic dis-
ease. (2) Arteriosclerosis with or without
hypertension. (3) Lues. (4) Infections.
(5) Fatty infiltration and degeneration.
Extrinsic: (1) Thyrotoxicosis. (2) Er-
rors of diet, excess of fluids and sodium chlor-
ide. (3) Alcohol. (4) Over-exertion and
over-physical development. (5) Psychic and
emotional disturbances.
There are 3 clinical types of cardiac failure :
(1) Congestive; (2) anginal; (3) the type
due to bacterial infection of the heart valves.
The first 2 types may be interrelated; that is,
in a patient with cardiac failure of the anginal
type, the pain may disappear and the patient
end his life in congestive failure, or a patient
in congestive failure may end his life sudden-
ly from occlusion of the coronary artery.
For the sake of convenience and clearness,
congestive failure may be divided into: (1)
Failure of the right heart; (2) of the left
heart; (3) of the auricles.
The purest example of right heart failure is
seen in pulmonary embolism, or may be en-
countered in pneumonia or in hypertension
where pulmonary edema develops suddenly,
with the left heart acting normally and the
pulse good. I once saw a patient develop
rapid and fatal pulmonary edema while the
chest was being aspirated in pleurisy with ef-
fusion ; the radial pulse remained fair until
the patient ceased to breathe. Right heart fail-
ure is also seen commonly in asthma, chronic
bronchitis and bronchiectasis, where the symp-
toms are markedly exaggerated by develop-
ment of right heart weakness. It is also
seen in arteriosclerosis of the pulmonary ar-
tery; the so-called “black cardiacs”. It is
common in mitral stenosis.
The commonest causes producing failure of
the left heart are, probably, rheumatic heart
disease and arteriosclerosis, with or without
hypertension, lues, and sometimes thyrotoxi-
cosis.
Failure of the auricles — auricular fibrilla-
tion— is without question the commonest
mechanism causing congestive failure. Au-
ricular fibrillation occurs most frequently in
(1) rheumatic heart disease; (2) senile or hy-
pertensive form of arteriosclerosis; (3) thy-
rotoxicosis ; (4) paroxysmal tachycardia with
an irregular rhythm. In auricular fibrilla-
tion, because of the high rate, the ventricles
do not fill up with each contraction, conges-
tive failure sets in early, and the blood be-
comes dammed back on the venous side.
Probably the earliest symptom of conges-
tive failure is dyspnea. This may be of 3
types: (1) On exertion. (2) Irregular
breathing of the Cheyne-Stokes’ type. This
is more apt to occur in older people with ar-
terial changes, with or without hypertension,
and may last for a long time, disappearing
when condition of the circulation improves
and reappearing when the condition becomes
worse. In 1 case under treatment, breathing
of the Cheyne-Stokes’. type persisted, off and
on, for a period of 1 year. (3) Dyspnea in
older persons manifested by the patients sud-
denly being aroused at night with a suffocated
feeling, being compelled to sit up for a while
to get his breath, then being able to lie down
again and go to sleep.
Sometimes dyspnea is the only symptom for
a long time ; gradually increasing. An old
lady, seen occasionally, has not been able for a
period of 1 year to walk across the room with-
out becoming extremely breathless. This type
is more apt to occur in failure of the right
heart. Sooner or later, in right heart failure,
pulmonary edema, or in mitral stenotic cases,
pulmonary hemorrhage may develop ; or, in
the predominantly left heart cases, edema of
the feet' or legs may begin. Some hyperten-
sive patients ha\re frequently repeated attacks
of pulmonary edema, and between attacks the
heart function seems to be good. I have a
lady under my care, with marked hyperten-
sion, who in 4 years has had many attacks of
pulmonary edema, usually brought on by un-
due exertion. When she recovers from these
attacks, each of which seems desperate, she
goes along doing her house work fairly com-
fortably.
As a rule, however, breathlessness and
826
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
edema of the extremities progressively in-
crease, the liver becomes enlarged and tender,
albumin appears in the urine, the veins become
engorged, fluid accumulates in the serous cav-
ities, and those pitiful cases of “cardiac
dropsy”, familiar to all of us, occur. We find
them sitting in a chair, cyanosed, breathing
with great 'difficulty, the lower part of the
body huge with massive edema, the skin of
the legs broken, oozing fluid, a nuisance to
themselves, a source of the gravest anxiety to
their friends, and often a severe trial to the
physician.
In congestive heart failure there are 2
things which must be considered ; first, pre-
vention, and second, treatment of the condi-
tion once it has occurred. It is along the
lines of prevention that, in the future, the
greatest advance must be made, and it is to-
ward this end that research must be directed.
At present our attempts are pitifully futile
in preventing the underlying cause of most
of our heart cases. If the rheumatic child is
treated as well, as assiduously, and along the
same lines as the tuberculous individual, much
can be done toward preventing recurrences of
rheumatic fever with its consequent and in-
creasing heart damage. Removal of focuses of
infection, prolonged rest, over-nutrition,
fresh air and sunlight, are all advantageous.
Unfortunately, some individuals seem pecu-
liarly liable to rheumatic infections, and her-
edity has some influence. I recently saw a
family where the mother and 3 daughters had
recurrences of rheumatic fever and endocar-
ditis. A cardiac child, in the interval between
attacks of rheumatic fever, feels very well,
and it is very difficult to convince the parents
that the child has a disease which should be
treated like a tuberculous case, with rest,
forced feeding, fresh air and sunshine.
In the hypertensive case, because we know
so little about the cause of hypertension, we
can do little specifically. Certainly where hy-
pertension lias lasted for years little can be
done toward a permanent reduction of blood
pressure, because of the secondary changes
which have occurred in the heart, blood ves-
sels and kidneys. Yet much can be accom-
plished with rest and diet. I have a convic-
tion that over-nutrition has much to do with
many cases of elevated blood pressure. I am
sure that I have been able, in the obese hyper-
tensive cases, to accomplish a great deal by rest
and a gradual and permanent reduction of
weight. In salt retention and nitrogen reten-
tion. salt and protein must be restricted, but
in my hands, the greatest good has been at-
tained in obese patients by reduction of the
carbohydrate and water intake so as to bring
about a gradual and permanent reduction of
weight.
In luetic cases, prevention and prompt and
efficient treatment when recognized should
prevent cardiac failure developing. Unfortu-
nately, the Wassermann test is frequently
negative when the lesion is undoubtedly luetic.
It is, therefore, safer to treat an aortic
regurgitation which has developed rather
quickly, in a man of 45 or 50, where the heart
was known to be normal a year or two before,
as a luetic aortitis, irrespective of what the
Wassermann discloses; this is particularly so
if there is no hypertension and the other ves-
sels do not show atheromatous changes.
When congestive failure has occurred, for-
tunately we have a medical armamentarium
which is extremely beneficial. Beginning and
increasing dyspnea always requires less work
and more rest ; a rest of V2 to 1 hour after
the midday meal and earlier hours for retir-
ing at night. Swelling of the legs or feet de-
mands a lessening of the fluid intake and a
restriction of salt. Cardiac edema is fortu-
nately the one type of edema which, if the
kidney is intact, is amenable to treatment and
readily responds to rest, limitation of fluid,
and restriction of salt. For many years I
have been using in the treatment of cardiac
edema a diet which meets the necessary re-
quirements of limited fluid and sodium chlor-
ide restriction. The diet is exclusively a fruit
diet consisting of raw or cooked fruit of all
kinds, including the fruit juices, the caloric
value of which may be increased by the ad-
dition of sugar, either cane sugar, lactose or
glucose. The only restriction is that not more
than 1 qt. of liquid be taken in the 24 hours by
the adult, proportionately less in the child;
usually something is given every 2 hours.
Such a diet is agreeable to most persons, fur-
nishes carbohydrate to burn the body fat, and
Xov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
827
combined with rest in bed will often without
any other measure cause disappearance of the
edema. After the edema has disappeared and
the condition of the heart improved, the diet
may be added to liberally ; meat, fish, chicken,
eggs, vegetables, milk, cereals and milk des-
serts. The fluids must still be reduced to 1
qt. each 24 hr., and the salt removed from the
diet or greatly reduced. If this plan is fol-
lowed it is rare for edema to recur, providing
the kidney still retains the power to remove
water from the body. With 1 patient who had
been in bed for 1 vear with massive edema, and
draining continuously, the edema has never
recurred. Another hypertensive case with
fibrillation and massive edema has remained
free for 5 years. I cite these 2 cases be-
cause in both instances the edema was very
severe and of long duration before treatment
was begun.
In cases of auricular fibrillation with a high
rate, usually the above measures alone are not
sufficient and some means must be found to
slow the heart. It is here that digitalis is of
profound value, but I am not altogether in
sympathy with the plan of administering huge
doses. I am sure that the danger of embolic
accidents is increased by following that plan.
Why, for instance, hit your patient with a
therapeutic sledge, when gentle tapping with a
jeweler’s hammer will be equally effective,
or why send a man to do a boy’s job? Of
course. I realize that where time is limited,
and danger imminent, the therapeutic sledge
hammer method may be necessary, as in the
following case. Mr. M., aged 38, with mitral
stenosis. After an attack of influenza, his
heart suddenly went into fibrillation with such
a high rate, 200, that in a very short while
marked symptoms of pulmonary congestion
and edema developed. He coughed contin-
uously, raising blood all of the time ; tracheal
rales appeared ; bloody froth at his lips and
oozing from his mouth; cyanosis and lividity
became extreme ; his pulse running uncount-
able. His condition was desperate. I had in
my bag some ampoules of bimuriate of quinin
and urea which, after a little prayerful
thought, were given intravenously. This was
not difficult as the superficial veins were so
markedly engorged. Within 20 seconds there
was a decided improvement ; the rhythm be-
came perfectly regular and the rate dropped
to 140. The bleeding stopped, due, I take it,
to the fact that because of the lower rate and
regular rhythm the ventricle filled more com-
pletely and lessened the pulmonary conges-
tion. Finally, the cough and bleeding stopped.
I thought at the time that the fibrillation was
converted into flutter, and polygraphic trac-
ings semed to bear out that conclusion. We
then started him on digitalis, according to the-
regular plan advised by Eggleston, with the
hope of improving his condition or possibly
returning his heart to normal rhythm. He
did improve, but his heart remained in fib-
rillation. The next morning his condition was
much improved and the heart rate much slow-
er. From then on his course was uneventful..
After 3 years, he is working every day with
his heart in fibrillation, the rate 80 to 90, and
is very comfortable.
Again, Mr. G., aged 59, a hypertensive
case of 10 years’ duration, was suddenly seized
with severe precordial distress, and pain ra-
diation to the bend of the right elbow, while
driving his car from 'office to home. In a
short time this was relieved, but recurred
when he walked from the garage to the house.
He was put to bed immediately, on a low diet.
Blood pressure was 200/110 but at the end
of a week had fallen to 160/110, and during
this week in bed he had no distress of any
kind referable to his chest. He then, of his
own volition, decided to get up and take a
bath. After the bath he was seized with
agonizing pain in his chest, substernal, with
radiation to both arms and to the little and
ring fingers of both hands. This pain con-
tinued despite hypodermics of morphia sul-
phate V\ gr. given every 4 hr. Amyl nitrite
and nitroglycerin were without effect. In 24
hours his temperature rose to 102°, and on the
following day a pericardial rub could be made
out. At the end of the fourth day he still
had the pain in his chest. In the evening of
the fourth day his heart, which had previously
been perfectly regular with a rate of 80. sud-
denly went into fibrillation with a rate of 190;
he became cyanosed ; his hands were cold and
828
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
clammy; and his radial pulse was hardly dis-
cernible. The situation, to my mind at least,
was desperate. Picture a heart with the cor-
onary artery occluded, an area of softening
developing as the result of occlusion, and be-
ing whipped up to a rate of 190. Clearly
something must be done to slow the heart
rate as soon as possible. Teaspoonful doses
of digalen were given every 6 hours for 3
doses. At that time the rate had fallen to 120
and the pulse was stronger. In 4-5 hours more
the heart had returned to its normal rhythm
with a ventricular rate of 70.
Such a reaction, with the astounding
changes which occur in the body and in the
heart, cannot help being accompanied with
considerable hazard. Visualize, if you will,
the changes in the heart which this sudden
change of rate means. The normal heart,
beating at a rate of 70, and allowing 2-4 oz.
for the amount of blood thrown into the aorta
with each contraction, moves through the body
each 24 hours from 8-16 tons of blood. If the
rate is doubled, the work of the heart is dou-
bled, and if trebled the work of the heart is
increased 3 times ; modified somewhat by the
tact that the rapidly acting heart does not
fill up completely with blood at each contrac-
tion. When the heart is suddenly slowed, the
marvel is that embolic accidents do not occur
more frequently. That they do occur, is be-
yond the shadow of a doubt. Another dan-
ger which occurs with the too sudden slowing
of circulation is the development of thrombo-
phlebitis. We have had 3 of our clinic patients,
in fibrillation, develop thrombophlebitis, 2 in
the veins of the lower extremities and 1 in the
veins of the left arm.
In a recent paper by Gold and Degraff,
mention was made of how little digitalis is
necessary in ambulatory cases of fibrillation
to maintain a slow rate and an efficient cir-
culation, often as little as 1-2 gi\ of the pow-
dered leaves a day kept up for years. This
has been our experience both in private prac-
tice and in our clinic. We have one patient
who gets coupled rhythm on 114 gr. of the
powdered leaves every other day. Their ob-
servations might be further extended to state,
that many, if not most, cases of auricular fib-
rillation in failure, rarely need the huge doses
of digitalis which it has been the custom of
recent years to give. In most cases the need
is not urgent, a few days are always avail-
able, and the heart can usually be brought
under control with moderate doses of digi-
talis, without the hazard which the larger
doses may entail. I saw a case recently where
the patient was having frequent Stokes-
Adams’ seizures, from digitalis which had
been given in massive doses to control a heart
in moderate fibrillation with hypertension.
There are some cases where speed is neces-
sary, but in my opinion, they are uncommon.
Where congestive failure with edema oc-
curs, in cases where the heart is regular and
the rate not high, or where the rate is high,
it is the general belief that digitalis, while it
may not reduce the rate, benefits the patient
and reduces the edema by its action on the
kidneys and the heart.
In addition to digitalis it is usual to give
some of the diuretic drugs to aid in the re-
duction of edema, particularly where the
simpler measures of rest, reduction of fluid,
and restriction of salt are not effective. Of
the diuretic drugs, in my hands the theobro-
min preparations are most effective. Theo-
bromin sodium salicylate, 10 to 15 gr. 3 or 4
times a day, is usually most satisfactory. The
theophyllum preparations, in my experience,
have no advantage over the above. The mer-
curials, novasurol and salyrgan are most pow-
erful diuretics and are often effective when
other measures fail ; however, they belong to
the list of therapeutic clubs occasionally neces-
sary but not to be used until simpler mea-
sures have failed. I have seen at least 3 ser-
ious results follow their use. One of saliva-
tion and severe colitis followed the injection
of 1 c.c. novasurol ; another of severe mer-
curial nephritis, with albumin, blood and
casts in the urine ; and a third with complete
suppression after I injection. It is the cus-
tom when using these mercurials, to precede
administration by a course of ammonium
chloride 10 gr. 3 times a day for 4 or 5 days.
' I do not believe patients with congestive
failure can be successfully treated while on
their feet, in a chair, or going to the bath
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
823
room. It has been my plan to insist on ab-
solute bed rest, until edema has entirely dis-
appeared and the condition of the heart im-
proved. This usually means 4 to 6 weeks in
bed, after which the rest must be partial, and
the activity gradually increased.
RADIOGRAPHIC DIAGNOSIS OF GALL-
BLADDER PATHOLOGY
Louis J. Gelber, M.D.,
Assistant-Attending X-Ray Staff,
Beth Israel Hospital, Newark, N. J.
In the study of the gall-bladder by oral
cholecystography, the mechanism and physi-
ology of the gall-bladder emptying must be
considered, and as regards physiology, one of
the first questions presented is : How does it
become filled with bile and how does it empty?
According to McMjaster, when digestion is
completed, the tone of the sphincter of Oddie
rises, pressure in the ducts increases, and as
soon as it reaches 70 mm., bile begins to flow
into the gall-bladder. During the process of
digestion, the sphincter of Oddie relaxes and
pressure in the ducts cannot rise above 120
mm. of bile because at that point the duct dis-
charges into the duodenum. It was also
found that pressure in the gall-bladder was
always low when the animal was fasting, and
was seldom more than 100 mm. of bile; it
always increased after eating foods like cream
and yolk of eggs. It is also interesting to
note that according to Holweg, 40 c.c. of bile
in the gall-bladder represents 350 c.c. of bile
from the liver; the gall-bladder bile having
about 10 times the density of liver bile, be-
cause bile pigments and salts were greatly con-
centrated in the gall-bladder. To clinically
prove this point, it was found that if the gall-
bladder was removed and the common duct
ligated, jaundice developed within 4 hours,
whereas, if the gall-bladder was left intact
and the common duct ligated, the gall-bladder
could store so much of the bile pigments that
jaundice would not develop in less than 48
hours.
It was upon this function of “concentration
of bile”, that the Graham-Cole test for gall-
bladder visualization was based, for here we
assume that a diseased gall-bladder will not
concentrate a dye containing iodin that is
excreted by the liver and will not become
visible in a roentgenogram.
However, because of the fact that a path-
ologic gall-bladder sometimes concentrates
well, it is essential to know that the muscular
coat of the gall-bladder is thin and that it only
contains one layer of fibers ; the connective
tissue layer under the serosa is nearly 3 times
as thick. It is this coat that is extremely rich
in elastic tissues and blood vessels, and when
even a mild grade of cholecystitis sets in we
find the elastic coat involved, causing dis-
turbances in the organ’s contractility and
distensibility.
In order to secure a good cholecystogram
after administering the halogenated phenol-
phthalein, it is essential that the stomach and
duodenum do not contain food. This is ap-
parent because if gastric digestion is in
progress, bile is permitted to enter the
duodenum by way of the common bile-duct
with the result that the bile containing
phenolphthalein will not enter the gall-bladder
to produce a shadow.
It has been proved by Graham that when
the hepatic ducts are ligated to prevent access
of bile to the gall-bladder, after injection of
tetra-iodophenolphthalein. the shadow remains
for many days, in spite of the ingestion of
egg yolk and cream which is supposed to in-
cite contraction strong enough to empty the
gall-bladder within a few hours. It seems
apparent, then, that the mechanism of empty-
ing the gall-bladder is complex in that, be-
sides intrinsic muscular contractions and
elastic recoil, the washing out of bile from
the gall-bladder through the liver is also ap-
parent.
Chronic inflammation in the gall-bladder is
expressed pathologically by increase of con-
nective tissue and accumulation of leukocytes
in the wall. Changes in the structure of the
gall-bladder abnormally are likely to produce
disturbances of its normal physiology. The
“absorptive activity” of the gall-bladder may
be one of the functions disturbed early by in-
flammatory reaction.
S30
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
Active inflammation and its results interfere
with the absorptive power of the gall-bladder
by involving the lymphatic and blood supply
and consequently they do not permit normal
concentration of the iodized phenolphthalein
which is used to produce the shadow after
exposure to Roentgen rays. This interference
with concentration expresses itself on the film
by a decreased density or by an absence of
the shadow of the gall-bladder.
Radiography is a “study of the contrasts
administration is resorted to, we make ex-
aminations at 15, 19 and 23 hours following
ingestion of the dye.
The visualized gall-bladder alters in size,
being largest at some period between the
tenth and twelfth hour, and becoming smaller
from that period onward. These changes
throw light on the distensibility and contrac-
tibility of the gall-bladder. These physical
properties are definitely shown after ingestion
of a fatty meal, where the gall-bladder shadow
The pressure gradient of bile.
in density”. Realization of this has led in-
vestigators to seek means for enhancing
contrasts or generating them where they are
non-existent. These efforts consisted of filling
hollow structures with a contrasting substance
of greater density than their surroundings,
and the procedure offers a vast amount of
information as to size, shape, position and
outline. The dyes employed in cholecystog-
raphy are excreted by the liver, reach the
gall-bladder in small but increasing quantities,
mix with the bile there present, and become
concentrated to the point where the gall-
bladder is opaque to x-rays. If alimentary
decreases markedly in size. In order for
these physical properties to manifest them-
selves the viscus must be free from any rigid-
ity, infiltration or inflammation within its
walls.
Pathology in the biliary tract may roentgen-
ologicallv be expressed by :
(1)
Non-visualization of the gall-bladder.
(2)
Faint visualization of
the gall-
bladder.
(3)
Delayed appearance of
the gall-
bladder.
(4)
Deformity of the gall-bladder ; con-
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
831
genital or acquired ; intrinsic or ex-
trinsic pericholecystitis.
(5) Cholelithiasis.
(6) Persistence of gall-bladder.
(7) Excessive size of the gall-bladder.
Non -Visualization
1. Obstruction of cystic
or common ducts.
2. Acute infections of
liver.
3. Absence of ga 1 1 -
bladder.
i 4. Ingestion of food.
5. Edema.
6. Pregnancy.
7. Kinks in cystic duct.
8. Malignancy.
9. Jaundice.
Faint-Visualization
r 1. Partial obstruction of
cystic or hepatic
ducts.
2. Mild grades of chole-
cystitis.
4 3, Lack of distensi-
bility.
4. Vomiting and lack of
dye.
5. Stout patient.
- 6. Asthenic.
Persistence of Shadow „
1. Abstention from food.
2. Reabsorption of dye
from intestinal tract.
3. Great amount of dye
given.
4. No evidence of path-
ology.
Excessive Size of Gall-
bladder
1. Obstruction to cystic
or bile-ducts causing
bile retention.
2. Congenitally en-
larged gall-bladder.
MYOCARDOSIS; THE FAILING HEART
OF MIDDLE LIFE
Further Observations
(No. 3)
Aaron E. Parsonnet, M.D.,
Newark, N. J., and
Albert S. Hyman, M.D.,
New York City.
The introduction of a newer concept of
cardiovascular changes in many individuals
approaching or past the so-called “middle-
age” grouping has naturally stimulated much
useful and needed discussion in regard to this
timely and fundamental question. With all
statistical tables pointing to a staggering mor-
tality from the degenerative diseases of the
heart and blood vessels in all age periods after
40, and its deadly selectivity among the most
useful and enlightened members of the com-
munity. it is small wonder that a need for
further clarification of this problem has
arisen.
Into every doctor’s office and into every
hospital clinic certain patients make their ap-
pearance, who carry with them a more or
less vague clinical syndrome which somehow
seems to gravitate toward the impression of
a failing heart. Yet, after the most thorough
and painstaking cardiovascular survey in
which has been used every conceivable aid
rendered by the most modern instrumental
and laboratory procedures, little if any specific
pathology is discovered. At the same time,
however, the experienced and well grounded
clinician will not be satisfied with this relative
summation of his findings and will reserve
judgment until further searching studies have
been made. To all of these cases the term
chronic myocarditis has been indiscriminately
applied in the past ; the inadequacy of this
loose and unscientific diagnosis has been ap-
parent to most physicians for many years.
Vast strides and continual advances made in
the field of cardiology and medicine in gen-
eral, have made the use of this term decidedly
untenable and a crying need for a better and
more specific designation has come about.
It is interesting, therefore, that although
this condition has been well known and well
recognized, it is only -very recently that any
serious attempt has been made to distinguish
and classify the failing heart of middle life
from the purely inflammatory types of acute
or chronic myocardial affections. Indeed, it
was not until 1929 that attention was sharply
focused upon the marked differentiation be-
tween the original concept of myocarditis , as
a manifestation of inflammatory phenomena,
and myocardosis, the degenerative phase. It
is to Riesman, of Philadelphia, a keen ob-
server, that we owe the selection of the word
myocardosis, which to our minds is peculiarly
fitting in filling the gap produced through our
increased knowledge of the cardiovascular
diseases. We may now define myocardosis as
832
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
a physiologic state engendered in the heart
and blood vessel system as the result of
coronary insufficiency with its accompanying
impoverishment of the myocardium. This
undernourishment, because of improperly reg-
ulated blood supply, leads to certain metabolic
disturbances in the heart as a whole, so that
the organ no longer is able to respond to the
various functional demands made upon it in
the course of every-day stress and strain. It
must be pointed out here that we are not
concerned with frank disease of the coronary
arterial tree, with its thrombosis, occlusion and
infarction phenomena; these are the later and
well-nigh hopeless terminal pathologic changes
which invariably develop in the course of de-
generative processes of this type. When the
coronary system has become so involved that
thrombosis occurs, no special problems of
diagnosis are presented ; many general and
specific methods of examination are now avail-
able to facilitate a correct estimation of such
pathology. Here the electrocardiograph,
x-rays, function tests, biochemical analysis,
and a clarified and distinct symptom-complex
are brought into play.
Myocardosis, in its earlier manifestations,
on the other hand, presents no such points for
clinical and laboratory analysis ; for this
reason, diagnosis and recognition of the con-
dition is far more difficult and uncertain.
Vague, indistinct, intangible and subtle
changes in the physiologic response of the
cardiovascular system as a whole to physical
demands, which previously have brought no
concern to the individual, now tax the
clinician’s sense of judgment and cumulative
experience. Into this group come many of
our middle-aged citizens with symptoms so re-
mote that more often than not these do not
arouse any suspicion or hint as to their true
origin and sinister significance. The brunt
of responsibility, therefore, rests upon the
examiner through whose early recognition of
this symptom-complex we may hope to re-
duce, or at least retard, development of true
coronary pathology or its uncomfortable
associate — angina pectoris.
Many observers have pointed out the ex-
istence of this form of lessened cardiac
efficiency, and to it have been given several
appellations. Christian, of Boston, considers
many of these patients as coming within the
group that he calls “non-valvular heart
disease”. His classification, however, falls far
short of describing the vast majority of such
patients, as the question of presence or absence
of valvular lesions hardly enters into the syn-
drome. What is of far greater importance
is the extent of coronary insufficiency sufifered
by individuals regardless of the status of their
valve mechanism. While it is unquestionably
true that valve damage in the younger age
groups is for most part of rheumatic- origin,
it has also been shown that the rheumatic
virus does not confine itself to the valves
alone and will affect any part of the cardiovas-
cular system. It is therefore conceivable that
coronary arterial changes of purely degener-
ative origin may be superimposed on a pre-
existing inflammatory process.
Winterberg, just prior to his untimely death
a few years ago, spoke of an important group
of presumptive cardiacs who with no previous
cardiovascular pathology suddenly suffered a
“plotzliche herzschwache”. In reviewing
these cases, he pointed out that a retrospective
diagnosis was always possible in these sudden
cases of heart weakening, and step by step the
gradual development and onset of the con-
dition could readily be traced. He made a
plea for a more careful examination of the
symptoms before they reached the stage of
heart failure, and he felt that sooner or later
a symptom-complex would be described in
which a potential diagnosis of the condition
might be made. Since publication of our first
paper upon the myocardosis syndrome, we
have been especially gratified by the almost
universal response stimulated by the intro-
duction of this newer concept of cardiovas-
cular impairment into clinical medicine. Both
in this country, and abroad, comments favor-
able, and some rather acrid, have shown the
widespread interest aroused by our concept
of this condition. Elmer and Rose, for
example, in the new edition of their very com-
prehensive text-book on Clinical Diagnosis,
have this to say :
“For the type of myocardial disease which is
purely degenerative, Hyman and Parsonnet have
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
833
suggested the term ‘myocardosis’. Only time will
tell whether this term will become a part of our
medical vocabulary, but it is important to dis-
tinguish in our minds the inflammatory from the
non-inflammatory diseases of the myocardium.”
In this connection it is interesting to com-
pare another recent volume upon heart dis-
ease; White approaches this subject from the
older and unsatisfactory point of view. Let us
quote his interpretation of this condition :
“The clinical diagnosis of ‘myocarditis’, so
freely used in the past, has wrongly included many
other conditions, in particular, the frequent in-
stances of hypertensive heart disease in which
there is cardiac hypertrophy and enlargement but
no inflammatory reaction in the muscle; the term
‘myocarditis’ has also wrongly included frequent
instances of coronary disease, in which degener-
ative changes, fibrosis and atrophy may occur
without actual inflammatory process. In the
attempt to diagnose heart disease more accurately,
the term myocarditis is being wisely abandoned
in large part; we must remember, nevertheless,
that there does exist occasionally such a condition
as myocarditis.”
Throughout this entire passage we see the
author groping for a term which would en-
compass his so-called “myocarditis” ; he does
not find nor use any and leaves us entirely un-
convinced.
We have indicated in our previous publica-
tions the fundamental pathologic origin of the
phenomena included in the term myocarditis,
either acute or chronic ; the component parts
of the inflammatory processes as they are seen
in the heart muscle, both from a clinical and
postmortem angle, form a separate and dis-
tinct picture from that seen in the myocardosis
syndrome, where no such inflammatory reac-
tions are observed. To consider a patient
suffering from coronary insufficiency, with its
attendant triad of symptoms — dyspnea palpi-
tation and substernal distress — in the light of
inflammatory disease is obviously fallacious.
Such individuals are not suffering from
chronic myocarditis, if the term is to be used
as an interpretation of pathologic change seen
in the inflammatory response of other organs.
Why should the heart be singled out and
burdened with a term that has no bearing upon
its true underlying pathology?
In selecting the term myocardosis the at-
tempt was made to sharply differentiate such
purely inflammatory changes from the dis-
turbances resulting from an inadequate
coronary blood supply to the heart muscle.
We agree with Wolffe in considering the myo-
cardosis syndrome as embracing a clinical
entity which includes within its symptomat-
ology certain manifestations of the cardiovas-
cular system unprepared and unable to meet
the usual demands of effort. In other words,
these hearts are found to be suffering from a
marked lessening of myocardial reserve
power, in spite of the fact that they have
practically no other clinical manifestations.
Three chief symptoms stand out above all
others; these are the original 3 steps to heart
failure, described by Kauffmann. In the
order of importance they are substernal dis-
tress, dyspnea and palpitation. When any
one of these, or a combination of them, sud-
denly develops in an individual approaching
middle life, who up to such time had been free
from such complaints, that patient may well
warrant a presumptive diagnosis of myo-
cardosis.
Substernal distress is a subjective sensation
which depends in great part upon the intel-
lectual level and introspective ability of the
individual in interpreting this type of dis-
comfort. Upon racial characteristics and
psychologic make-up will depend the degree
with which patients will complain about
this symptom. I.ocalized and more or less
limited to the substernal area, it most fre-
quently occurs after physical exertion. When
it develops after stair climbing or walking up
slight inclines, in persons who have habitually
performed such daily tasks as a part of their
occupational routine, it becomes a striking and
dominant part of the patient’s symptomatol-
ogy. Indeed, it may be this single fact which
brings him to the physician’s office, in contrast
to the symptoms of dyspnea and palpitation. It
has been our "experience that middle aged in-
dividuals presenting this symptom demand
close scrutiny and repeated cardiovascular
study, for sooner or later unmistakable evi-
dences of myocardial breakdown will become
apparent. These cases must not be confused
with the mild types of angina pectoris which
respond therapeutically to the vasodilators.
The onset of dyspnea may be more difficult
of analysis; Kauffmann was fond of making
the observation that no one could determine
when the normal physiologic response of
breathlessness after exercise became the
834
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
pathologic entity of heart failure. Given
enough stairs to climb, even the most perfectly
conditioned athlete will eventually suffer from
dyspnea, but his return to normal will be
smooth and rapid ; in the middle-aged in-
dividual who suffers breathlessness on a short
flight of stairs, his return to the resting state
may be a prolonged and painful process. So
far as this latter individual is concerned, many
factors must be considered in estimating the
degree of cardiac impairment ; occupation,
physical make-up and the overweight inci-
dence all play an important role in determin-
ing the pathologic aspect of dyspnea.
Although many tests have been devised to
measure the dyspneic factor, none can be
applied with greater accuracy than a com-
parison of a subject’s physical activity over
a given period of time. To measure the
breathlessness of a laborer by the same stand-
ard as that of a sedentary clerk is obviously
fallacious ; the only yard-stick of standardiza-
tion must be the individual’s own reaction to
routine effort.
Palpitation, or heart consciousness, ap-
parently occurs with equal frequency from
youth to old age ; in many instances it seems
to be of no special pathologic import. When,
however, a middle-aged person, who previously
experienced no such complaints, appears be-
fore his doctor because of palpitation, this
symptom also warrants careful evaluation. If
the heart consciousness is due to an irregu-
larity of cardiac rhythm, the symptom is more
easily interpreted than when no change or
interruption in the pulse rate is observed.
Taken together, therefore, the symptoms of
substernal distress, dyspnea and palpitation
may be regarded as the great 'triad of sub-
jective sensations experienced by patients
undergoing the initial stages of coronary in-
sufficiency. To these may be added the more
remote and much more elusive symptoms of
insomnia, gastro-intestinal upsets and per-
sonality changes. It is not our intent here
to enter into any long and elaborate dis-
cussion of the variegated symptomatology of
the myocardosis syndrome ; this we have
given elsewhere.
We have merely attempted here to repeat
our objections to the concept of chronic myo-
carditis which is so prevalently held in spite
of its glaring inadequacies both pathologic
and clinical. We have tried to show that there
exists a definite physiologic state which
antedates the frank development of coronary
arterial disease. This period is associated
with no demonstrable pathology and its recog-
nition rests solely upon the observational
acumen and judgment of the physician alone.
We believe that it is only during this period
that any serious attempt to curb or combat
the relentless progression of the vascular de-
generative changes in the heart is possible.
Myocardosis, therefore, must be regarded as
more than a new name for an old disease; it
is, as a matter of fact, a designation spelling
a new approach to the understanding of the
earliest manifestations of coronary insuf-
ficiency.
FUSOSPIROCHETAL DISEASE OF
THE LUNG*
F. J. Altschul, M.D.,
Long Branch
Visiting Physician Monmouth Memorial Hospital,
Long Branch, and Monmouth County Tuber-
culosis Hospital, Allenwood, N. J.
C. A. Pons, M.D.,
Asbury Park
Pathologist Monmouth Memorial Hospital, Long
Branch, and Ann May Memorial Hospital,
Spring Lake, N. J.
W. G. Herrman, M.D.,
Asbury Park
Roentgenologist Monmouth Memorial Hospital,
Long Branch, and Ann May Memorial Hos-
pital, Spring Lake, N. J.
We wish to call your attention this after-
noon to a variety of pulmonary lesions which,
though previously regarded as distinct dis-
eases, are really different manifestations of
one type of infection, namely: infection by
certain spirochetes and fusiform bacilli closely
allied to those which cause Vincent’s angina.
Some of the pulmonary lesions caused by this
group of organisms have received scant atten-
*(Read at the 165th Annual Meeting of the Medi-
cal Society of New Jersey, at Asbury Park, June
4. 1931.)
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
815
tion until very recently, while others, notably
lung abscess and gangrene, have received con-
siderable attention both as to pathogenesis and
therapy. A formidable literature has accumu-
lated about lung abscesses during the past
decade, but it is only recently that the bac-
teriology of lung abscess has been thoroughly
studied, and that experimental work has shown
the majority of lung abscesses to be caused
by aspiration of the anaerobic group of mouth
organisms — fusiforms, spirochetes, vibrios and
certain streptococci.
The change that has come about during the
last few years concerning the etiologic sig-
nificance of spirochetes in these lesions is
dramatically shown by the following : In one
of the well known medical reference works
published in 1928, George J. Heuer, Pro-
fessor of Surgery at the University of Cincin-
nati, writing on lung abscess and gangrene,
states that spirochetes only very rarely cause
lung abscess, and mentions them not at all in
his discussion of gangrene ; but in an article
published in February. 1931, the same author,
reviewing the recent literature on lung abscess,
apparently concludes that probably in 75%
of lung abscesses, in 80% of cases of bron-
chiectasis, and probably in all cases of gang-
rene, the mouth anaerobes, of which spiro-
chetes are members, are probably important
causative factors.
The term — fusospirochetal disease of the
lung — is probably open to criticism, inas-
much as the vibrios and streptococci are also
factors in producing the various lesions, but
the term is found in the recent literature and
it correctly emphasizes the importance of the
fusiforms and spirochetes in the etiology of
the disease, especially as these organisms give
to the lesions their most characteristic clinical
finding, namely, foul smelling sputum. In
the past, these cases have gone under names,
without etiologic specificity, of putrid bron-
chitis, bronchiectasis, atypical acute and
chronic bronchitis, unresolved pneumonia,
pulmonary abscess, and gangrene.
It is interesting to note that the spirochetes
were demonstrated in the sputum and in sec-
tions from the lung in a case of putrid bron-
chiectasis and pulmonary abscess as early as
1867, by Leyden and Jaffe, in Holland, al-
though no significance was attached to the
finding. Rona, in 1905, described the finding
of spirochetes and fusiforms in necropsies of
2 patients with gangrene. Castellani, working
in Ceylon, described in 1906, and later in 1909,
some cases which presented clinical pictures
resembling tuberculosis, but in which the
x-ray findings were not characteristic and no
tubercle bacilli could be demonstrated in the
sputum. In these cases the sputum revealed
many spirochetes which Castellani believed to
be a specific type and which he called “spiro-
cheta bronchialis”, and to the condition he
gave the name “bronchopulmonary spiro-
chetosis”. And, we may mention here that
Castellani made no mention of the presence of
fusiform bacilli.
Following Castellani’s report, several other
cases of bronchopulmonary spirochetosis were
reported, but all were from tropical countries
and until 1918 spirochetal infection of the
lung was generally considered a tropical dis-
ease of which only a few cases had been de-
scribed. The first cases on record in the
United States are those reported by Johnson,
from Mississippi in 1909, and by Rothwell
from Missouri in 1910. These men found
fusiform bacilli and spirochetes both in their
cases. Johnson labeled his cases “bronchial
Vincent’s angina’’.
That relatively little attention had been
given to fusospirochetal lung infection is best
evidenced by the fact that only 150 cases of
all types had been reported in this country up
to 1929. During the past 6 years, several
articles have appeared in the literature, con-
tributing greatly to our knowledge of pul-
monary spirochetosis; especially important
have been the contributions of Pilot & Davis,
Kline & Berger, and David T. Smith. David
T. Smith, of Raybrook, N. Y., has probably
reported the greatest number of cases and has
done the best and most convincing experimen-
tal work, of which, however, we will mention
only a few important features : Small pieces
of membrane from patients with Vincent’s
angina, inoculated into the groin of a guinea-
pig. produced a local abscess containing or-
ganisms identical with those in the original
material. Pus from such abscesses, when in-
troduced into the trachea of rabbits, produced
836
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
a series of lesions comparable to those found
in man: pneumonitis, gangrene, abscess and
bronchiectasis. This indicated that these var-
ious forms of clinical diseases have a common
etiology in the anaerobic mixture of spiro-
chetes, fusiform bacilli, vibrios and cocci pres-
ent in Vincent’s angina. None of these or-
ganisms alone would reproduce the disease,
but a mixture of all 4 resulted in a typical
fusospirochetal abscess in the groins of mice
or guinea-pigs, and pus from those abscesses
caused a typical fusospirochetal lesion in the
lungs of rabbits.
Similar lesions were obtained in rabbits by
introducing, intratracheally, material from
cases of abscess, bronchiectasis and pyorrhea.
Though Smith showed that a combination of
spirochetes, fusiforms, vibrios and cocci were
essential to produce the various lesions, there
is no doubt that the spirochetes and fusiforms
are the really important members of this
group, in so far as they are the ones that
destroy elastic tissue and are the primary in-
vaders.
The spirochetes isolated from cases of pul-
monary spirochetosis have been of different
morphologic types and have been given var-
ious names, a few being: Treponema micro-
dentium. Treponema macrodentium, Spiro-
cheta Vincentii, Spirocheta bronchialis, Spiro-
cheta buccalis, etc. These are all, probably,
pleomorphic forms of the same organism. Vin-
cent has shown that the same spirochete de-
veloped in different tissues may take on vari-
ous dimensions and thicknesses, and may vary
in the number of spirals and in motility. The
number and amplitude of the spirals vary ac-
cording to the state of vitality of the spiro-
chete. There is also much evidence to show
that the fusiform bacillus is really a spiro-
chete in a different stage of development. One
of us (C. A. Pons) has observed almost pure
cultures of fusiforms converted to spiro-
chetes of various morphology.
It is now definitely known that the group of
organisms under discussion can cause at least
5 types of bronchopulmonary lesions :
( 1 ) Acute, subacute and chronic bronchitis ;
(2) primary bronchiectasis; (3) pneumoni-
tis; (4) pulmonary abscess; (5) pulmonary
gangrene. No doubt several factors come into
play in the various cases, determining the type
of lesion produced, severity and virulence of
the infection, location and extent of the dis-
ease and resistance of the patient.
In spirochetal bronchitis and bronchiectasis
the infection is limited to the bronchial wall.
Chevalier Jackson and other bronchoscopists
have reported ulcerations of the bronchial
walls caused by spirochetes. If the ulcera-
tions are limited to the mucosa, the picture of
a severe bronchitis, occasionally with bloody,
foul expectoration, will be noted ; in such
cases the x-ray picture may be negative.
Chronic cases of this sort may strongly re-
semble tuberculosis in their symptomatology.
It is very likely that the great majority of
cases of primary bronchiectasis are due to
spirochetal infection.
Bronchiectasis is treated, even in the latest
text-books, as being always secondary to me-
chanical causes, and no mention is made of a
larger group, of cases which are primarily and
result from spirochetal infection. Smith de-
scribed development of these cases as follows :
“The mucosa is destroyed and the micro-
organisms, ever striving to get away from the
free oxygen on the surface, advance further
and further into the bronchial wall. The
elastic tissue framework of the bronchus is
destroyed, and portions of it may be found in
the sputum in the form of small compact
bundles of elastic fibers. The blood vessels
in the bronchial wall are eroded, causing blood-
tinged sputum or actual hemoptysis. With the
destruction of elastic tissue there is a gradual
dilatation of the bronchus somewhat similar
to the dilatation of a blood vessel following
destruction of its elastic tissue by Treponema
pallida. After the elastic and muscular layers
of the bronchus have been destroyed, the dis-
ease may extend into the surrounding lung,
causing an extensive loss of pulmonary tissue
and producing what is commonly called a
bronchiectatic abscess. (Whether the result-
ing dilatation will be sacculated, fusiform or
cylindric, probably depends upon the numbers
and positions of the primary points of in-
vasion in the bronchial wall.) When the dis-
ease process is checked, nature attempts to
heal the lesion by fibrosis. Dense scar-tissue
forms all along the bronchus, and this leads
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
837
at times to partial or complete stenosis, so
that areas of constriction may alternate with
areas of dilatation. In acute lesions, the sur-
face of the bronchial ulceration is ragged and
congested, but later, when the inflammatory
process has subsided, the normal mucosa at
the edges of the lesion may grow down and
cover over the surface of the dilated area.”
Pneumonitis. In many cases the organisms
will invade the lung parenchyma and produce
inflammatory lesions which may be sharply
circumscribed or diffuse, with or without
cavity formation. The pulmonary infiltration
when diffuse may be either lobular or lobar in
distribution and may invade either the upper
or lower lobes. From a roentgenologic stand-
point these lesions, particularly When in the
upper lobes, may greatly resemble tuberculosis.
Undoubtedly these areas of pneumonitis are
the precursors of abscess and gangrene.
Abscess. The lesion of uncomplicated fuso-
spirochetal abscess is that of a broncho-
pneumonic consolidation with central ne-
crosis. The process is at first acute and often
becomes subacute and chronic. The most
common site is the right lower lobe, although
any lobe may be involved. Severe lesions may
be multiple from the beginning or there may
be rapid spread from the primary abscess and
formation of new abscesses. In this spread-
ing type of lesion there is great tendency to
gangrene and the abscess cavities show mark-
ed necrosis with green discoloration and in-
tense putrid odor.
At the beginning there is a wall of collateral
inflammation which, in chronic cases, later
becomes replaced by dense fibrous tissue.
Kline, Pilot, Smith and others have all re-
ported the peculiar arrangement of the or-
ganisms in zones through the experimental
abscess and in those cases that have come to
necropsy. Sections through the abscess show
masses of bacteria of various types in the
central necrotic area; peripheral to this, a
zone where the spirochetes are mixed with
the vibrios and cocci, and an outermost zone
composed of pure spirochetes (sometimes with
fusi forms) which seem to be invading the
normal tissues.
Pulmonary gangrene shows a fulminating
process in which destruction of pulmonary
tissue is extensive and rapidly progressive.
Our interest in bronchopulmonary spiro-
chetosis was aroused, principally, by the work
of D. T. Smith a little over 2 years ago.
Since then we have been continually on the
qui vive for cases which we knew to be more
common than was ordinarily supposed. We
have been particularly interested in discover-
ing early bronchial involvement, although
many of our cases have been those of exten-
sive pneumonitis, abscess and gangrene.
During the past 2 years we have observed
29 cases of fusospirochetal abscess of the lung.
Of these. 26 cases have been carefully studied,
treated with sulpharsphenamin, and personally
followed, and they form the basis of this
report. Of these 26 patients, 14 were from
our ward service at the Monmouth Memorial
Hospital; 3 were from the Monmouth
County Tuberculosis Hospital, at Allenwood;
3 were from private practice; and 6 were
seen in consultation with other physicians.
There were 10 females and 16 males, and
ages ranged between 20 and 40 except for a
boy of 12.
These 26 cases have been divided into the
following groups
(1) Acute fusospirochetal bronchitis (4
cases) .
(2) Primary fusospirochetal bronchiec-
tasis (5 cases).
(a) Acute (2 cases).
(b) Chronic (3 cases).
(3) Fusospirochetal pneumonitis (10
cases) .
(a) Simple diffuse (5 cases).
(bl With bronchiectasis (2 cases).
(c) With cavity formation (3 cases).
(4) Fusospirochetal pulmonary abscess
(6 cases).
fa) After tonsillectomy (2 cases).
(b) After tooth extraction (1 case).
(cl Spontaneous (3 cases).
(5) Fusospirochetal pulmonary gangrene
(1 case).
At this point it might be well to say a word
about our method of examining the sputum.
As it is well known that 80% of normal
mouths and 100% of septic mouths harbor
838
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
spirochetes, certain measures were necessary
to prevent contamination of the sputum with
the mouth spirochetes. So, sputum was wash-
ed through successive changes of saline and
a small piece of purulent sputum was removed
from the center to make a very thin smear. We
have used Fontana and various other stains
but have found the Harris modification of the
Kliewe stain the best for demonstrating spiro-
chetes. The sputum should be fresh hnd ex-
amined immediately because it has been shown
that spirochetes disintegrate very rapidly.
Quite often we found spirochetes only after
repeated examinations.
That spirochetes and fusiforms are not
secondary invaders is shown by the fact that
they are not found in other lung lesions. Smith
failed to find spirochetes and fusiforms in
150 cases of uncomplicated pulmonary tuber-
culosis. in 6 cases of asthma, and 5 cases of
mycotic infection of the lung; and we failed
to find them, though searched for repeatedly,
in cases of pulmonary tuberculosis, asth-
ma and other chronic pulmonary affections.
The following is a summary of the findings
in the 26 cases studied:
Cough 26
Expectoration 26
Foul sputum 24
Fever 25
Loss of weight 20
Pleural pain 14
Hemoptysis 12
Night sweats 8
Chills 5
Dental sepsis 18
Infected tonsils . . 10
Spirochetes found 26
Fusiforms found 26
Vibrios found . . 12
Physical signs 24
X-ray findings positive 23
Wassermann and Kahn positive . . 6
Wassermann neg. and Kahn pos. . 3
Treatment in these cases consisted essentially
of the administration of sulpharsphenamin in-
travenously, and postural drainage. The av-
erage number of injections was 5; the average
dose given was 0.6 gm. The number and fre-
quency of dosage was influenced by the type
of case and severity of the symptoms. A
definite improvement was noted in practically
every case as soon as sulpharsphenamin was
administered.
We are aware that other spirochetal drugs
have been used successfully in this disease
(especially bismuth), but we have had ex-
perience only with sulpharsphenamin. We ob-
tained good results in all early cases with it,
so continued with its use. Postural drainage
was carefully carried out in all cases of abscess
and bronchiectasis and we feel that this pro-
cedure also played a great part in the recovery
of these patients.
The results of treatment were:
Cured
Improved
Unimproved
Bronchiectasis
5 cases
2
3
—
Bronchitis
4 cases
Pneumonitis
4
10 cases
7
3
—
Abscess
6 cases
2
2
%
Gangrene
1 case
1
—
—
—
—
—
Total
16
8
2
We wish to present the following cases in
our series of 26 with fusospirochetal infec-
tion. as illustrations of the various types of
lesions encountered :
Case Histories
Acute fusospirochetal bronchitis. S. P.,
aged 24, mechanic, colored, was admitted with
the diagnosis of Vincent’s angina, severe and
existing for 10 days. Two days before ad-
mission had marked cough with purulent ex-
pectoration. There was marked gingivitis,
with ulceration in the pharynx, and coarse
rales were heard over both lungs anteriorly
and posteriorly. Sputum was copious, sanguin-
opurulent ; and contained myriads of fusi-
form and spirochete organisms. X-ray ex-
amination negative. Wassermann 4- 2.
Sulpharsphenamin was given on admission,
and 3 days later the expectoration was mark-
edly diminished and cough very slight. Pa-
tient signed release from hospital, and his
family physician reported that after 1 other
sulpharsphenamin injection the cough and ex-
pectoration rapidly diminished and he has re-
mained well ever since. The Vincent’s infec-
tion of the mouth cleared up in a short time.
A similar case was that of F. J ., aged 28, a
colored laborer, who had a sudden onset of
illness with chill, general malaise and cough 3
days before admission. Cough soon became
productive of a blood-tinged, purulent sputum.
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
839
No definite hemoptysis and no chest pain. Ad-
mitted with diagnosis of influenzal broncho-
pneumonia. He had a marked dental sepsis,
and many coarse rales were heard throughout
the right chest anteriorly and posteriorly; no
signs of consolidation. Sputum showed myr-
iads of fusiforms and spirochetes. Wasser-
mann and Kahn tests were negative.
Sulpharsphenamin was given 3 times with
intervals of 3 days. Temperature down after
the third injection; rales practically all dis-
appeared ; general condition much improved ;
sputum diminished. Recurrence of tempera-
ture, with increase in the cough and expec-
toration, followed in 10 days, but another in-
jection of sulpharsphenamin effected a gradual
improvement until at the end of 2 weeks
there was a normal temperature and negative
physical findings ; sputum very scant and
negative for spirochetes ; radiograph shows
accentuation of pulmonic regions in the upper
right lung ; fluoroscopic examination shows
slightly diminished aeration of both sides.
Fusospirochetal bronchiectasis. J. G., aged
15, a white student, had a cough, with copious
expectoration for 9 months ; occasional pain
in the chest ; running a slight afternoon tem-
perature for 3 weeks. At times the sputum
has been blood-tinged but has not had a definite
hemoptysis. Frequent colds as a child. Ad-
840
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
mitted with diagnosis of pulmonary tuber-
culosis. Well nourished young boy; tonsils
diseased ; coarse rales over the right base pos-
teriorly. Sputum was negative on repeated
examination for tubercle bacillus but fusi-
forms and spirochetes were found. X-ray
After 2 injections of sulpharsphenamin,
temperature remained normal : cough and
sputum greatly diminished, and spirochetes
disappeared.
Acute fusospirochetal pneumonitis. Mrs. E.
V., aged 32, white housewife, was admitted
picture before lipiodol injection shows accen-
tuation of pulmonic markings of both bases,
particularly the right ; near right hilus there
was a large fibrous ring. After lipiodol in-
jection, marked bronchiectasis was noted over
the right base. (See Fig. 1).
to the Monmouth Memorial Hospital with
diagnosis of tuberculosis. For 3 weeks pre-
viously the patient endured a cough which
after a few days became productive of a thick,
purulent sputum ; 1 week before admission
had a brisk hemoptysis; also had night sweats
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
841
and pain in the right chest. There was mark-
ed dental sepsis ; infected tonsils ; chest-dul-
ness and diminished breath sounds over the
right base posteriorly ; and coarse rales over
the right upper lobe posteriorly and over the
left base. Sputum was copious, sanguino-
purulent for a few days and (4-8 ounces daily)
contained myriads of fusiform and spiro-
rates slightly. A lipiodol injection shows slight
bronchiectasis. (Fig. 4). Patient gained 15 lb.
in weight and when seen 2 weeks after dis-
charge had no cough, expectoration, nor any
other symptoms referable to her chest.
This case, we feel sure, would have gone on
to abscess formation if the diagnosis of spiro-
chetal disease had not been made and treat-
Fig. 3. Fusospirochetal Pulmonitis 2 weeks after treatment.
chetes. Wassermann and Kahn -j- 4. Radio-
graph on admission showed infiltration of the
extreme right base. (Fig. 2).
Sulpharsphenamin was given every 4 days
for 5 doses and sputum diminished in amount
after the second dose. Radiograph taken 2
weeks later shows improvement (Fig. 3) ;
another. 4 weeks later, shows chest completely
cleared, but patient still coughs and expecto-
ment instituted early. It is interesting to note
that this patient was syphilitic. We believe
that many of the cases reported as being lung
syphilis, because of clearing under arsphenam-
in therapy, are fusospirochetal infections.
Diffuse fusospirochetal pulmonitis with cav-
ity formation. T. A., aged 27, white salesman
(patient of Dr. J. E. Maher), was admitted to
the Monmouth Memorial Hospital November
S42
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
3, 1930. Perfectly well up to 4 weeks before
admission when he began to experience sharp
stabbing pains in the left chest radiating to
the shoulder, and he had developed an unpro-
ductive cough with fever and dyspnea. Diag-
nosed as pleurisy. The pain remained for
cryptic and markedly diseased ; impaired
resonance at the left base posteriorly; dim-
inished breath sounds of the, entire left lung
with faint bronchovesicular breathing at the
left base posteriorly; fine and medium coarse
rales heard over the entire chest posteriorly
Fig. 4. Fusospirochetal Pulmonitis 6 weeks after treatment. Lipiodol Injection,
showing slight Bronchiectasis.
about 4 weeks, after which the cough became
productive of a thick purulent sputum, and 4
days before admission the sputum increased
in amount, became blood-tinged, and had a
distinctly foul odor ; about 8 oz. daily. Teeth
and gums in good condition ; tonsils large,
and in the left axilla; few fine rales anteriorly.
Sputum showed myriads of fusiforms and
spirochetes, and some comma-shaped bacilli
(vibrios). X-ray picture shows slight pleural
exudate in the upper left lobe; interlobar
pleurisy. Marked infiltration extending into
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
343
the costophrenic angle. The entire condition
appeared to be a pulmonitis of the left upper
and lower lobes. (Fig. 5).
Sulpharsphenamin .03 gm. administered
November 5 and .06 gm. on the tenth. Pa-
tient showed no marked improvement until
2 weeks after first injection, when breathing
became easier, and cough slightly diminished
though still productive of a thick, foul spu-
tum. Three doses sulpharsphenamin .06 gm.
each were given November 19, 24 and 30,
and patient, discharged December 22, went
to work shortly afterward, and did not re-
turn for reexamination until January 10,
1931, at which time the cough, expectoration
and pain in the chest had returned. Sputum
examination showed again many fusiforms
and spirochetes; radiograph showed reactiv-
ity in the lung at the left base. One injec-
tion of sulpharsphenamin was given within
4 days and the symptoms improved to such
an extent that the patient was again dis-
charged.
Since his second discharge from the hos-
pital his physician states that he is very unco-
operative and has failed to return for injec-
tions, stating that he feels perfectly well,
coughs little and rarely expectorates. Radio-
graph taken in April shows marked improve-
ment over his previous picture but still shows
844
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
some fibrosis in the left lung. At this time
there are no spirochetes or fusiforms in the
sputum.
We believe that this case shows extensive
infiltration clue to spirochetes, fusiforms and
allied organisms, with abscess formation ; the
focus being in the tonsils. We feel that if
developed pain in the right side of her chest,
with fever and a dry cough ; condition diag-
nosed as pleurisy. She quickly recovered and
seemed well until February 25, when she be-
gan to raise copious amounts of foul smelling
sputum. \t this time the temperature was
102°. The cough and expectoration became
Fig;. 6. Spontaneous Fusospirochetal Pulnionitis Abscess in right upper lobe.
Note fluid level.
the diagnosis had not been made, this case
would have gone into pulmonary gangrene
and ultimate death.
Spontaneous fusospirochetal pulmonary ab-
scess. (Patient of Dr. K. Brown.) Mrs. V. H.,
aged 36, white, housewife, was perfectly well
until January 12, 1931, when she suddenly
more pronounced and the patient, becoming
worse, was admitted to the Ann May Hos-
pital on March 11. at which time she was
coughing up quantities of a foul-smelling,
purulent sputum, occasionally blood-tinged.
Examination of this sputum on several occa-
sions failed to show tubercle bacilli but show-
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
845
ed many spirochetes, fusiforms and vibrios.
An x-ray picture taken March 12 showed a
definite abscess in the right upper lobe. (Fig.
6). Patient appeared critically ill, was suf-
fering from marked anemia ; transfusion was
done; and 3 injections of sulpharsphenamin
were given intramuscularly at 4 day intervals
tion became less and the temperature grad-
ually came down; sputum examination April
17 showed no spirochetes or fusiforms and
had no foul odor. Patient has been under
observation of her physician since discharged
from the hospital and at present seems to be
in the best of health, without cough or ex-
with no marked improvement. An injection
intravenously, on March 30, and 3 more in-
jections were given at 4 day intervals there-
after. Almost immediate improvement was
noted after the first intravenous; improve-
ment gradually became more marked during
the ensuing 2 weeks ; cough and expectora-
pectoration. Radiograph taken May 15 shows
remarkable improvement. (Fig. 7).
Fusospirochetal gangrene of the lung. J.
M., aged 39, colored laborer, was admitted
with the diagnosis of acute rheumatic fever;
for 2 weeks previously had polyarthritis with
high temperature ; acutely ill man with mark-
846
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
ed swelling of the knees, wrists, elbows, and
left ankle. Teeth and gums in fairly good
condition, although there were 2 crowned
teeth that looked suspicious. Tonsils mark-
edly congested, cryptic and enlarged. (Pa-
tient states that at the onset of joint symp-
right axilla. From this time on, the patient
gradually became worse, the cough and pain
increased, and definite dulness, with broncho-
vesicular breathing, developed in the right side
just below the angle of the scapula. Diagno-
sis of pneumonia was made. The patient’s
Fig. 8. Fusospirochetal Puimonary Abscess after tooth extraction. Roentgenogram
taken 3 months after onset of symptoms. No improvement after
Sulpharsphenamin therapy.
toms he had a very severe sore throat.) Af-
ter receiving salicylates for 1 week the joint
symptoms improved, but he developed cough
and pain in the right chest which increased on
deep breathing; and 3 days later a few fine
and medium coarse rales were noted in the
cough became productive of a thick purulent
sputum which was definitely foul in odor and
slightly blood-tinged. This was examined for
tubercle bacilli, fusiforms and spirochetes but
none were found. Suddenly, he became very
much worse, an x-ray showed a diffuse peri-
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
847
bronchial and pulmonary infiltration in the
right lung extending from the hilus in all di-
rections evenly on all 3 lobes, and the picture
was that of a pulmonitis resulting from hilus
infection spreading over equally in all direc-
tions. Costophrenic angle Was relatively
clear. (Fig. 9). Then he had a severe fit of
coughing, with a brisk hemoptysis of- about
4 oz. of pure blood. Examination of sputum
at this time showed many spirochetes, fusi-
forms, vibrios, streptococci and elastic tissue.
The condition gradually became very much
worse, temperature running high, cough and
foul. Physical signs gradually diminished and
a radiograph showed marked clearing of the
right side lesion. There was still diminution
in aeration and some evidence of fibrosis.
(Fig. 10). Patient was finally discharged with
negative physical findings and a temperature
which had been norma! for several weeks,
and when seen 3 months later was back at
work and had no symptoms referable to his
pulmonary experience. Wassermann in this
case was -j-4.
It is interesting to note that this man de-
veloped gangrene of the lung while in the
Fig. 9. Fusospirochetal Pulmonary Gangrene.
purulent expectoration increasing to a very
marked degree and having a severe hemopty-
sis every other day. From the clinical pic-
ture, the character of the sputum which was
indescribably fetid, and from the x-ray find-
ings, the diagnosis of gangrene of the right
lung was made. The quantity of the sputum
averaged from 10-15 oz. daily, and after
standing it separated itself into the classic 3
layers. Injections of sulpharsphenamin were
given and improvement was noted after the
fifth; temperature began to fall and the spu-
tum to diminish in amount and become less
hospital, having been admitted for an entire-
ly different condition, namely, rheumatic
fever. It is also interesting to speculate on
the source of the spirochetes that, undoubted-
ly, caused his gangrene. He had no dental
sepsis, but he did give a history of having had
a severe sore throat at the onset of the rheu-
matic fever, at least 3 weeks before onset of
the gangrene. It may be that he harbored
these organisms in his respiratory tract for
some time and that his other ailments lowered
his resistance, so that it was only after sev-
eral weeks of illness that his resistance was
848
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
so lowered that the spirochetes were able to
produce damage. The rapid spread of the
disease showed that once the organisms en-
tered his lung, the infection spread like wild
fire. It is interesting to note, particularly,
that the disease had gained great headway and
that extensive gangrene of the lung had oc-
curred before proper treatment was instituted,
but that in spite of this, marked clinical im-
provement was noted after the fifth injection
of sulpharsphenamin and complete cure after
the eighth injection.
been realized hitherto. Probably 80% of
bronchiectasis cases and 75% of lung ab-
scesses are caused by this type of infection.
(2) Though spirochetes are present in
80% of normal mouths, they are found in
huge numbers in patients with dental sepsis
and diseased tonsils. In these cases, huge
numbers of these organisms are probably as-
pirated into the bronchi and broncho-alveolar
recesses. The aspiration of these organisms
may follow operations about the oral cavity
Fig. 10. Fusospirochetal Gangrene G weeks after treatment.
Conclusions
From a study of the recent literature, and
from our own study of 26 cases of fusospiro-
chetal pulmonary suppuration observed be-
tween May 1929 and May 1931, we present
the following conclusions :
(1) Various types of pulmonary suppura-
tion (fetid bronchitis, primary bronchiectasis,
certain types of pneumonitis and certain cases
of abscesses or gangrene), up to very re-
cently regarded as unrelated entities, are
really different manifestations of infection by
spirochetes and other anaerobes closely allied
to those causing Vincent’s angina. This type
of infection is much more frequent than has
and general anesthesia or may occur sponta-
neously.
(3) In cases of chronic pulmonary sup-
puration where the tubercle bacilli and fungi
are not found, search should be made for
spirochetes and fusiform bacilli. Foul smell-
ing sputum certainly should always lead one
to search for spirochetes. These organisms
do not stain well with the ordinary dyes and
are usually overlooked in the routine exam-
ination of sputum, but are usually demon-
strated with the Harris modification of the
Kliewe stain or Fontana stain.
(4) When treated early and intensively,
the various lesions found in fusospirochetal
I
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
849
Nov., 1931
disease of the lung respond readily to sulph-
arsphenamin. In cases of early pneumoni-
tis, pulmonary gangrene, and pulmonary ab-
scess, this improvement is often dramatic,
even in the face of extensive pathology de-
monstrated by x-rays.
Cases of chronic lung abscess with exten-
sive fibrosis around the abscess cavity do not
respond to sulpharsphenamin and probably
should be treated surgically, but even in these
cases sulpharsphenamin should be used prior
to operation.
(5) Postural drainage is an important
part of the treatment, particularly in bron-
chiectasis and abscess cases.
(6) Prevention of these lesions depends
on proper oral hygiene.
DISCUSSION
Dr. William P. Belk (Philadelphia) : I have for
10 years been pathologist at Bryn Mawr Hospital,
in a suburb of Philadelphia, and, though aware in
a vague way of this type of lung lesions. I never
until recently found such a case. About 4 months
ago Dr. Pons told me of the work you have just
heard reported, and explained how to examine
sputum. Since that time I have examined 45 in-
dividuals who might possibly have had this in-
fection, and of those, found 7 to be typical cases;
a positive finding of 15%. Inasmuch as this con-
dition is easily confused with pulmonary tuber-
culosis, I reviewed the results of examining 100
consecutive sputums for tubercle bacilli. They
were positive in 12% of the cases. These num-
bers are small, but I think quite significant, and
I should like to suggest, which is probably true,
that fusospirochetal disease of the lungs is as
common in ordinary hospital practice as is pul-
monary tuberculosis. That the Vincent’s organ-
ism is etiologic in this condition is proved, beyond
doubt, by the experimental work of Smith and
Kline, Berger and others. I have recently, my-
self, Without any difficulty, produced very char-
acteristic lesions in the lung of a guined,-pig by
injecting into the groin material from the teeth of
an individual with pyorrhea; the lesion in the
lung was crowded with spirochetes and fusiform
bacilli.
I wish to read to you 1 case history, not be-
cause it is spectacular, but because it isn’t: It
is a very simple, ordinary case such as we all see
very often. This is a white female, 27 years of
age, who is a house maid. She said she had
coughed ever since she could remember. In Jan-
uary of this year her cough became worse and
she visited the medical clinic in Bryn Mawr Hos-
pital. She was afraid she would lose her position
because the cough was annoying her mistress.
Her physical examination was entirely negative,
including the lungs. Her health was good; blood
count normal, Wassermann negative. The radio-
graph was that of a typical chronic bronchitis.
She was treated with the ordinary cough mixtures,
several cf them being tried, without result. Even-
tually, the sputum was examined and found to be
negative for tubercle bacilli, but to contain a large
number of spirochetes. She was given 4 intra-
venous injections of neo-arsphenamin, at the end
of which time she was distinctly better, but still
coughed some, and the sputum contained a few
spirochetes. The last injection caused toxic symp-
toms. For that reason emetin was given, 4 in-
jections on 4 successive days. A week following
this, upon visiting the hospital, she was very
happy because her cough had practically entirely
ceased. Her sputum was then examined and
spirochetes found only with great difficulty and
after a prolonged search. I think this case is im-
portant to us all because it is such a simple thing,
a simple chronic bronchitis cured, I believe, by a
specific form of treatment.
I would like again to emphasize to you, what
I am sure is true, that this disease is common, that
it is productive of very much pathology, and that
there is for it a very satisfactory, specific form of
treatment.
Dr. W. G-. Ilerrman (Asbury Park) : I would
like to emphasize the variety of lesions that are
seen roentgenologically in these cases and to urge
everybody to be on the watch for them. I sup-
pose that patients in many of the hospitals rep-
resented here, are handled much as they are in
ours; patients come with a preliminary diagnosis
of some form of respiratory infection, and often,
prior to any clinical examination or history tak-
ing, they are sent to the x-ray laboratory, and
the roentgenologist is supposed to express an
opinion on what he finds. In such cases we know
nothing about any sputum examination. Unless
we question the patient ourselves, we know noth-
ing about the history. You have seen here the
wide variety of lesions that can be caused by this
type of infection. I do not think that it is only
tuberculosis with which it may be confused. So
far as the x-ray picture is concerned, unless the
radiographs are viewed with the history in mind,
there is oftentimes no characteristic appearance.
Of course, a lung abscess will be diagnosed as a
lung abscess, but I have noticed that in many of
the cases with pulmonitis, either single or multiple
areas, that lung striations will be quite visible
through the involvement, and the lesion will not
appear as a definite consolidation. Such lesions
should at once throw you on your guard. As Dr.
Altschul has told you, spirochetes burrow through
the wall of the bronchus, and a true peribronchial
infiltration and exudation is produced. We feel
that there are a great many cases of this infec-
tion now going unrecognized, so far as the exact
nature of the offending organisms is concerned.
The possibility of a fusospirochetosis should be
considered in every case of respiratory infection,
unless you have a frank case of pneumonia or
pulmonary tuberculosis.
Dr. O. A. Pons (Asbury Park) : For a number
of years I have been reporting on the presence
of spirochetes in the sputum without exciting any
interest on the part of the clinicians. Two years
ago I found numerous spirochetes in a man’s spu-
tum. He was discharged from the hospital, only
to return with an extensive pulmonary gangrene.
If you look for spirochetes you are going to find
them, but you must use special stains, and when
found they should be numerous.
Another interesting case was one in which Dr.
Parry, of the Spring Dake Hospital, removed a
gangrenous appendix. Had I not cut that ap-
pendix, the diagnosis of spirochete disease of the
appendix would have been lost. The foul smell
on sectioning the organ led me to make smears,
850
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
and later a Levaditi on the sections, and I am
happy to say I have shown them to Dr. Belk, and
he agrees that it is as typical a case of spirochete
infection as you would want to find from mouth
lesions.
CLINICAL EVALUATION OF A CON-
CENTRATE OF VITAMINS A AND D*
Joseph H. Marcus, M.D.. F.A.C.P.,
Atlantic City. New Jersey
It is interesting to note that years before
vitamins were known, some physicians rou-
tinely prescribed cod-liver oil for certain
types of patients. One type embodied those
patients having low resistance, those who
caught “colds” easily ; such patients were
told to take cod-liver oil from November to
April. The acutely conscious physician with
years of experience had frequently observed
that when persons with a tendency to upper
respiratory infections took this form of medi-
cation, they increased their resistance and
were less susceptible to colds during the win-
ter months. Certainly, this deduction was
purely empiric, but it is, nevertheless, in close
harmony with present day scientific observa-
tions, which stress the relationship between
vitamin A and its anti-infective properties.
Investigators have ascertained that the marine
diatoms synthesize the vitamin A, and that it
is transferred to the tissues of minute animals
which thrive on the unicellular plants. These
in turn form the food supply of larger species,
particularly, small fish which in their turn are
devoured by the larger fish, such as the cod.
Through all these stages, there is apparently
a transference of the vitamin, ending finally
in storage in the liver of the cod. The modern
methods of manufacturing cod-liver oil do not
especially lower the vitamin value but there
apparently exist variations in its value, prob-
ably connected with the seasonal changes in
the feeding habits or physiologic conditions of
the fish.
Clinical interpretations, coupled with ob-
servations on laboratory animals, lead us to
*(Read at the 165th Annual Meeting of the
Medical Society of New Jersey, Asbury Park, June
4, 1931.)
agree with the theory of the older physicians,
that the constituents embodied in cod-liver oil
comprise a significant element in preventing
illness prevalent in the so-termed “respiratory
months”.
In an early discussion of cod-liver oil, Os-
borne and Mendel made the following state-
ment: “It is perhaps more than a mere coin-
cidence that cod-liver oil has so long enjoyed
a reputation for nutritive virtues which can
scarcely be attributed to its fat content per
se.” In view of the recent investigations con-
ducted with animals and humans, the question
has naturally arisen as to whether this po-
tency is due to vitamin A.
McCollum and Davis were the first to ob-
serve in animals the relationship of respira-
tory infections to a diet deficient in vitamin
A. but similar deductions were reported by
Drummond. These findings were confirmed
by Steenbock, Sell and Buell, and further
substantiated in the respiratory realm and in
other infections by Mellanby and Green,
Pfannensteil and Scharlau, Nakahara, Man-
ville, Tyson and Smith, Bradford, and others.
There appears to exist but little doubt regard-
ing the importance of the fat-soluble vitamin
A in human nutrition, and certain phases of
individual well-being both in experimental
animals and man.
Quite recent observations are reported by
Tilden and Miller on 11 monkeys kept until
death on a diet containing but 6 to 12 units of
vitamin A daily, and on 6 monkeys main-
tained on a similar ration except that it con-
tained from 250 to 700 units of the vitamin
each day. The symptoms of illness noted in
the monkeys receiving the low vitamin diet
were loss in weight, followed later by ano-
rexia, colitis and death; while 6 monkeys on
control diet, with 1 exception remained well
and gained weight. This single monkey de-
veloped a non-fatal dysentery. Turner and
others found that pyogenic cocci are more
frequently encountered in those animals that
show the most severe symptoms of vitamin
A deficiency. Further evidence is offered
that cod-liver oil protects the nasal cavities
and middle ear against bacterial invasion.
Lassen’s experiments were confined to para-
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
851
typhoid bacilli, in which he found that re-
sistance to this organism was markedly de-
creased by a deficiency of vitamin A. At the
International Pediatric Congress held in
Stockholm, 1930, Alfred Hess stated that
“irradiation alone and its equivalent had no
effect on infections of the upper respiratory
tract and did not prevent them”.
In the present stage of scientific interpre-
tation it is generally conceded that cod-liver
oil exerts a specific action both in the pre-
vention and treatment of rickets. In spite of
known qualities in the past as an antirachitic,
and its more recent attribute as an “anti-
infective” agent, its use has not been as free
as its therapeutic qualities would warrant.
Gordon and Flanders, in a recent clinical sur-
vey, concluded that the effects of cod-liver oil
concentrate on various respiratory symptoms
suggested that supplementary vitamin A ad-
ministration is of distinct value. It was also
noted that a sensation of well-being and in-
creased appetite appeared in 35% of his pa-
tients. Wharry observed that “patients bed-
ridden from causes other than tuberculous,
and not treated with fatty foods or cod-liver
oil, often developed urinary troubles of an in-
fectious and very serious nature”. Sherman
has stated that “with so much direct experi-
mental evidence of wide-spread weakening of
the body when the intake of fat soluble vita-
min is low, it is not surprising that this diet-
ary deficiency should have been assigned as a
contributing factor in such diverse diseases
as rickets, tuberculosis and pellagra”.
During the past few years, many have pre-
ferred the pure vitamin D preparations, which
allow exact dosage, in prevention and cure of
rickets. Cod-liver oil, however, also contains
vitamin A, the importance of which had been
unjustly relegated to the background by
scientific research concentrating on the vita-
min D element. Where the supply of vitamin
A is missing or lacking to an appreciable de-
gree. there is no growth and keratomalacia,
pyelitis and other infections develop; indicat-
ing a diminished resistance to bacterial infec-
tion. Beumer states that this has been de-
monstrated not only by animal experiments
but, unfortunately, also by involuntary whole-
sale experiments in institutions where babies
had been fed skimmed milk.
The use of cod-liver oil as a remedy has a
long history, and has been admirably present-
ed by Guy. Records of its use by physicians
do not appear until the end of the eighteenth
century, but 20 years ago Rosenstern wrote:
“Cod-liver oil is in the forefront of children’s
remedies. For long it has been struggling
against the skepticism of exact science.” Scha-
bad, in 1900, first demonstrated in metabolic
experiments that cod-liver oil possesses cer-
tain peculiar properties regarding the utiliza-
tion of calcium and phosphorus in connection
with the study of fats in relation to rickets.
As early as 1754, a Dr. Percival called atten-
tion to the value of cod-liver oil in the treat-
ment of rheumatism. He lived among fisher-
men and found that for generations they had
used cod-liver oil in treating the disease, con-
tending that since it softened leather it should
soften stiff joints. Perhaps he advocated its
use both internally and externally.
Most clinicians have recognized the value
of cod-liver oil following infections of the
respiratory tract, but very few have stressed
the importance of its administration as a pro-
phylactic agent in respiratory conditions. Its
alternative qualities have been acknowledged
as embracing one of the best available tonics,
observing caution, however, against its use
in digestive disorders, avoidance in cases in
which there is a fat disturbance, and conced-
ing that it is not well borne during hot
weather.
Mariott called attention to the danger that
may arise in the use of ergosterol indiscrim-
inately as a substitute for cod-liver oil ; the
former containing vitamin D alone, but having
its specific usage in rickets, tetany and osteo-
malacia.
I cannot agree with some writers who state
that children possess an instinctive liking for
cocl-liver oil. Lust suggests that older chil-
dren be given a chocolate or peppermint tab-
let before and after the oil. It seems hardly
necessary to mention that the successful use
of vitamins A and D in cod-liver oil depends
entirely upon its administration in such form
as to provide for ready aeceptability and sub-
852
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov.. 1931
sequent efficient absorption and assimilation.
The flavored oil did not offer the child marked
inducement for ready acceptability — and for
various reasons emulsions, jellies, capsules,
wines and extracts failed either from a thera-
peutic or from a palatable viewpoint.
With the introduction of ergosterol the
pediatrician was enthusiastically receptive,
feeling that in this product there was offered
a substitute for cod-liver oil, which could be
used in a like manner— without its accom-
panying deterrent features. Experimental re-
searches soon demonstrated the necessary
presence of vitamin A, which was lacking in
ergosterol ; relegating it, as a distinct entity,
to its rightful place in therapeutic distribu-
tion of vitamin D.
In the search for a more generally accept-
able embodiment of vitamins A and D, wafers
of cod-liver oil concentrate were used in the
Betty Bacharach Home for crippled children
for 7 months from November 1, 1930 to June
1, 1931. The ages ranged from 18 months to
16 years and included both bed-ridden and
ambulatory patients, comprising diseases of
the nervous system, bone and glandular tu-
berculosis, osteomyelitis, heart affections,
rickets, and malnutrition ; a total of 70 chil-
dren. Similar observations were carried out
in a boarding institution, ages ranging from
6 months to 10 years, a total of 25 children.
Practically all children were kept under un-
interrupted observation. The medication was
crushed for the infants and given in the bot-
tle or with the cereal — and the tablets were
handed to children at stipulated hours. Dosage
for infants and younger children was 3 wa-
fers daily — and older children received 6-9
tablets daily.
Taste. No child resented the taste but, on
the contrary, many expressed a desire for
them. A few, knowing their relationship to
cod-liver oil, objected at first but this distaste
was quickly overcome after a few doses.
Appetite. Certain children, whose appe-
tites were apathetic, showed an increased in-
terest in food at meal time- In all patients,
lessening of the appetite or nausea was not
experienced, and increase in weight was a no-
ticeable factor.
Administration. The wafers may be crush-
ed and put in the bottle for an infant. It has
also been advisable to mix the dose with the
cereal for those infants who did not finish the
bottle but took the entire cereal feed; thus
insuring entire dosage.
Toxicity. Apparently there exists no im-
mediate or cumulative toxic element in taking
larger doses of these tablets. One child, 3
years of age, chewed and swallowed 20 wa-
fers on one occasion without any functional
or organic disturbance.
Conclusions. The routine usage of sufficient
amounts of vitamins A and D has a back-
ground embodying scientific and justifying
results.
In evaluating the types of experiments, it
seems reasonable to conclude that vitamin A
assumes a significant role in the defensive
mechanism of the experimental animal, as
well as the human. Our present knowledge
obviously indicates that a liberal supply of
fat-soluble vitamins is a highly potent factor
in maintaining a satisfactory measure of
health and vigor. Clinical interpretations,
coupled with observations on laboratory ani-
mals, lead us to agree with the theory of the
older physicians that cod-liver oil (due to the
presence of vitamins A and D) will assist in
preventing illness prevalent in the “respira-
tory months”.
Cod-liver oil concentrate can be included
in the dietary of the infant and child, and it
appears that benefit can be derived therefrom.
Proper hygiene, a well-balanced diet, with
sufficient caloric intake, must always be ac-
companying factors. Given to 6 rachitic in-
fants who had clinical signs and symptoms of
rickets, moderate to marked improvement was
noticed in all.
In a general survey of the incidence of re-
spiratory conditions, especially of the upper air
passages, it was felt that there existed a les-
sened tendency to this type of infection. Dur-
ing the winter months the community ex-
perienced a more or less general influenza epi-
demic, moderate in intensity. The 2 insti-
tutions mentioned were practically devoid of
any contagion. Cod-liver oil concentrate was
administered daily to 95 infants and children
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
853
without interruption for a period of 7 months,
it is readily acceptable and appears to offer an
L topian form of cod-liver oil therapy, con-
taining adequate amounts of vitamins A and
D.
DISCUSSION
Dr. Kenneth Blanchard (East Orange): I have
been much interested in Dr. Marcus’ paper and
want to say that from my own clinical experience
I can, in some measure, support his results on
cod-liver oil concentrate. Since February 1, we
have been conducting a clinical study of the value
of a council-accepted, cod-liver oil concentrate in
tablet form, at the Orange Orphanage, where I
happen to be Attending Physician. We have had
50 children on such treatment, the number being
split into eoiual groups, and the oil group being-
used as controls. While the study has not yet
progressed far enough to permit drawing final
conclusions on the value of the oil over the con-
centrate, or vice versa, 1 or 2 facts are outstand-
ing. It is unquestionably easier to secure routine
administration with the concentrate which the
children regard as a confection. The appetite of
the group on concentrate is better than that of
the oil group, due to the fact, I believe, that the
fats are absent.
Also, the ease with which the concentrate is
given secures much better cooperation from the
nursing staff than when the oil is given; due to the
palatability of the tablets. This winter, at the or-
phanage, we have come through with a marked
decrease in the incidence of upper respiratory in-
fections, and have had no epidemic of contagious
disease despite the influenza prevalent in that
section. Furthermore, those children who had
formerly failed to gain, have shown noteworthy
gains in weight and height on the concentrate.
And, perhaps because of their physical well-being,
they show better deportment.
Dr. H. B. Silver (Newark) : It is very interesting
to observe how little we learn from even the re-
cent past. We listen to Dr. Marcus’ paper, which
was very interesting and the facts are undoubtedly
of value, but we forget what was said about
viosterol several years ago. The whole vitamin
study is Just opening up and I do not feel that we
are quite justified at the present time in recom-
mending any preparation, for after you check your
vitamins A and D you do not get the same re-
sults as with cod-]iver oil. We thought that we
got from viosterol the same good effects as cod-
liver oil gives. My feeling is that cod-liver oil con-
tains a great deal that we know nothing about. We
know something about the vitamins A and D
but there may be numerous other vitamins that
we know little about, also lipoids and fats in the
content of cod-liver oil. I have not found so much
difficulty in the use of cod-liver oil in private prac-
tice and I think the tendency should be to stay
with cod-liver oil as much as possible for routine
work and use other substances only when we can-
not use the cod-liver oil.
Dr. Stanley Nichols (Long Branch); Dr. Marcus
asked me to say a word about his paper. I think
we will all agree that a clinical evaluation is a
difficult thing in any field and pediatrics is no ex-
ception. I am sure there is a place for cod-liver
oil concentrate. Time only will show how great a
place. None of us has any doubt that cod-liver
oil increases resistance. The work of the North-
western Reserve Pediatric Staff has shown us a
great many things in a more exhaustive way.
They included also adults in their cod-liver oil
and other vitamin studies. Taking a large num-
ber of adults and children in Cleveland, over a
period of years, they were able to reduce markedly
their respiratory difficulties. When you have a
control like that, you have a clinical evaluation of
great merit.
Dr. Marcus said that administration of these vi-
tamins was only necessary from November to
April. I am sure we all used to feel that way but
I have grave doubts now as to whether that is so.
In the summer time, particularly when we have
prolonged rainy seasons for 7-10 days, and there
is no sunshine, it seems to me at such times it is
essential to give these children some cod-liver
oil. It has also been stated that it cannot be
given in the summer time. I used to subscribe to
that, along with the idea that you cannot give oat-
meal to babies in the summer time, but I have
been giving cod-liver oil in the summer for the
past 4 or 5 years, in decreased doses, because I
believe we do not always have enough sunshine
to meet the requirements.
I was interested this winter in having some of
my pediatric friends in Florida send their patients
back here. From that place where the sun shines
all the year round, babies came back taking 1
or 2 teaspoonsful of cod-liver oil a day. I have a
notion that those men, some of whom are very
careful observers, think that even Florida’s sun-
shine sometimes is not enough to prevent rickets.
I have seen Florida children, born and raised there,
come here and show signs of rickets. I believe we
should give some cod-liver oil in hot weather, and
particularly in summers that have little sunshine.
I would like to say one thing about rickets,
and that is that many pediatricians are discouraged
with the use of cod-liver oil. They expect to cure
in one generation the accumulated rickets of
all time. We see patients who have not much ten-
dency to rickets and seem to thrive without any very
marked amount of antirachitic substances. I think
it will take a number of generations of routine ad-
ministration of cod-liver oil or its substitutes to
get rid of rickets, and we must not expect it to
happen in a single generation. Spasms of the
spasmophilic group have been reduced greatly by
antirachitic measures. Whether we agree with Dr.
Silver or not, as to whether cod-liver oil may con-
tain some other substance, no product has yet
been found that equals cod-liver oil. The concen-
trate certainly has a field because we live in a time
when the mothers like the simplest way out and
they welcome viosterol which we were told had no
difficulty for the digestive tract, although some
of us do not believe that. I have seen some chil-
dren who have had digestive trouble following its
use, which ceased on stopping its administration.
So far as the concentrate is concerned, I think we
can use it largely with the type mother who wants
the simplest way out and here she has a fair sub-
stitute for cod-liver oil. We notice by recent re-
searches that there are other foods that now con-
tain vitamin D. I hope the manufacturers will some
day find something that will taste and smell better
than cod-liver oil.
Dr. Joseph H. Marcus (Atlantic City): Skepti-
cism indulged in by the physician of today is no
doubt warranted. “Life is short and art is long.”
As in the case of ergosterol, it was soon em-
phasized through clinical analysis and laboratory
evaluation that this product maintained a specific
854
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
relationship to the prevention and cure of osteo-
malacia, rickets and tetany, and could not be
safely used as a substitute for cod-liver oil from
all angles. It does not contain vitamin A but is
a distinct vitamin D element. Dr. Nichols’
thought embodies an ideal gesture. . . remove the
objectionable features from cod- liver oil and retain
the vitamins A and D. The full vitamin A and D
content has apparently been removed in the small
non-saponifiable fraction and embodied in these
cod-liver wafers, that were administered to in-
fants and children for 7 months.
LOOKING AT THE FACTS IN THE
HIGH COST OF MEDICAL CARE*
Erwin ReissmAn, M.D.,
Newark, N. J.
When I was a boy at school in Vienna,
it was customary to devote an hour twice a
week to religious instruction. While all
children of any different faith were permitted
to recess during this hour, it was my habit
to stay in occasionally and listen. Once one
question was asked which I, for some reason
or other, was able to answer. Thereupon
this clairvoyant priest turned to the class and
said: “This boy will be a President some day.”
The pride which I then felt was as noth-
ing compared to the pride that was mine
the day when you elected me President of the
Academy of Medicine, 2 years ago. I want to
assure you in all humility that I am grateful
for and mindful of that honor and I take this
opportunity to express to you my appreciation.
Anything that may have been accomplished,
however, during that time could not have been
done without the cooperation, courtesy and
moral encouragement of my associates on the
Council and without the active support of all
members. I hope that you will extend the
same courtesies to my successor, Dr. Eagleton.
This Academy, from a lowly beginning, has
developed in 20 years into an institution of
magnitude such as very few cities of our size
can boast of and, with certain policies now
inaugurated, it is destined to grow still further
under leaderships far abler than mine. At
this, the end of tenure of office, it is customary
for the President to deliver a message. This
♦(Address as retiring President of the Academy
of Medicine of Northern New Jersey, May 21, 1931.)
message should leave behind a grain of
thought and may, with your cooperation and
guidance, lie developed into something useful
and worth while.
A topic which is today uppermost in the
minds of the profession and the public is
the high cost of medical care, or rather, the
high cost of being sick. Representing as we
do a large majority of the scientific medical
men in our community, a problem such as
this is of paramount importance to the mem-
bers of the Academy of Medicine. Any
remarks which I make in the discussion of
this subject are entirely impersonal, are di-
rected against no specific individual, and
should not be accepted as critical of any
institution. The problem, as it strikes me,
is to be considered as a whole, and a remedy
found if possible.
Wingate M. Johnson, in an article in the
Atlantic Monthly, recently said : “It is an open
season for Doctors the year round” and, as
you know, when this high cost is being con-
sidered, the doctor seems to be the one who
is again held largely responsible. Casual
observation and only cursory study will show
you that this is not true. The problem is four-
fold and concerns the doctor, the hospital,
the nurse and the public. In this country
we have about 150,000 doctors to 120,000,000
population. The average yearly income of
these doctors has been estimated from as
low as $2000 in rural communities to about
$6000 in the larger cities. This is very little
when you consider that a physician spends
more than $12,000 cash and 7 years of his
time to fit himself for the profession. Most
doctors are honest, industrious and hard
working men, who are vastly underpaid for
the services they render.
Hospitals, which have developed from in-
stitutions intended for the poor into palatial
structures designed to attract the wealthy,
in spite of big fees demanded, are always in
debt. Nurses, who have risen to the daily
wage of $7 to $8, are employed only part of
the year and therefore their earnings are
proportionately low compared with the
services that they should give. Bear in mind
that emphasis on “should”.
These are incontrovertible facts for which
Xov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
855
no single agency is responsible and which can-
not be laid at the door of Jew or Gentile,
American or Foreigner and which will not
he remedied solely by race or religion. This
is an existing economic problem developed,
fostered and encouraged by modern standards
of living for which all of the people are
equally responsible. Considering these items
individually, it seems as if nobody is making
money and that everything is as rosy as it
should be.
How does all this affect the sick individual
who has to pay the collective charges, and
how can they be reduced? Let us follow the
simple process of a sudden sickness invading
the home of a family with an earning power
of, say S100 per week. It may be the head
of the family, the wife, the child or a de-
pendent member, who is stricken. At first,
self-medication is resorted to. That, of
itself, is an expensive habit, for it delays
recovery, often intensifies the disease, and
causes loss of time. Dr. Shuler, Editor of
Ladies Home Journal, speaking editorially,
concludes his remarks with the following :
“Much of the high cost of medical care is
not due to the doctor, the system of treatment,
excessive fees in nursing, hospitalization, or
medical work. It is due to our own improper
demands, and to our expensive and usually
ineffective attemps at self-medication.” This
self-medication failing, a doctor is called in.
It may be the family doctor or a neighboring
physician. If he is able to cope with the
disease early, the final cost is indeed very
small. Should the illness become more com-
plex, or the family panicky, a consultant is
demanded, a nurse may become necessary, and
thus the cost is immediately and enormously
increased. The nurse in the home gets $8
per day and $8 for night duty, plus food ;
the consultant from $10 to $150; incidentals
$2 to $3 per day ; and the poor doctor, who
takes all the responsability and blame, $3 to
$5 per visit. Let us suppose that the disease
is pneumonia, which can be treated in the
home and which may last 4 to 5 weeks. The
approximate charge of the attending physician
would not be more than from $100 to $200;
the nurses would get from $400 to $500 ; the
consultant, the laboratory fees with drugs and
incidentals, may be anywhere from $50 to
$300. according to the size of the fee and the
ponderosity of the consultant. Thus, a simple
case of pneumonia becomes an inordinate
drain which takes nearly J4 of the family’s
yearly income. Suppose that this patient is
treated in a hospital where, private rooms can
be had at $7 to $14 per day. Immediately,
and often without real necessity, numerous
laboratory examinations are made, transfu-
sions may be resorted to, oxygen chambers and
what not are required, and there you would
have the expense more than doubled. When
the daj" of reckoning comes, all these demands
and requisites are forgotten and the cold bill is
all that remains. I have a few of such actual
cases in mind, one of which I will cite here
as an example.
A young married woman with a child,
whose husband has today an earning capacity
of $75 per week. She was ailing for a few
weeks till, finally, an acute intestinal lesion
developed. She was then more or less acutely
ill for 10 weeks, 5 of which were spent in a
hospital and 5 in her home. The total cost
of this illness was more than $5000. The
nursing fees exceeded $1150 without the cost
of meals ; the hospital charges were $600 for
the 5 weeks ; the consultants $400 ( 1 New
York man charging $150 each for 2 calls) ;
a minor operation, with subsequent difficult
attendance, was $750; 4 transfusions with
donors cost $750. The original attending
physician, who carried the patient through
the entire illness, including attendance before
full development of the disease, received about
$650. I ask you, in all sincerity, to place the
blame where it belongs.
Hospitals, as I -said before, have developed
into institutions of magnificence. In their
newer building programs they vie with each
other in the construction of imposing edifices
stretching out over acres of ground, marble
halls, sumptuous attendants, complicated office
systems, social service departments, and all
the multifarious dofangles of big business
without the necessary intelligence, efficiency
and business sense to properly conduct them.
Winford H. Smith, Director of Johns
Hopkins Hospital, says in the Saturday Even-
ing Post: “It all seems verv complicated, but
856
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
actually the situation presents the same sort
of disorderly picture that has induced our
leading industries to engineer better organiza-
tions for themselves. Whenever an industry
does this, the usual results are better service
and lower prices to consumers and greater
rewards for those- engaged in the industry.
In spite of the fact that the medical care of
a nation never can be strictly a matter of
buying and selling, nevertheless, there is no
field of activity today which is in sharper
need of better coordination than medical
service.”
Such hospitals have private rooms costing
from $7 to $14 per day. As soon as a
patient enters, the entire armamentarium
begins to function, until the final cost averages
about $20 per day without doctor’s fees and
nursing. In spite of all this, there is not 1
hospital in this country which can compare
in equipment, design for comfort, convenience
and service, with modern hotels and yet their
cost is far in excess. The hotels make money
and the hospitals lose. Why? In my
humble opinion — and this notwithstanding our
so-called authorities on hospital construction —
hospitals should go in for height instead of
width. A 20-story building on a 150 ft. lot
is of greater convenience, and much less ex-
pensive to conduct, than an 8-story building
spread out over several acres, with wings and
outhouses and a large overhead. The cost
of maintenance is thereby reduced. Fewer
employees are needed, and time and labor are
saved — to say nothing of the lower property
cost. I believe also that the daily fee for
rooms should include, free of charge, all
routine examinations because, to my mind,
no hospital room is worth $*14 per day unless
such services are there, easily obtainable, and
ready for use free of all cost.
Let us take the nursing problem as it
exists today. A student nurse after 2-3
years of study, for which she is now paid
and for which she ought to pay, is graduated
and is then immediately available at the
regular price of $7 to $8 per day. This same
fee is charged the patient who pays $7 per day
for a room, as well as to the one who pays $14
per day. Why? Would it not be more equit-
able if recent graduates, obviously lacking in
experience and knowledge, would for the first
year or so confine themselves to work requir-
ing less exacting duties and to those patients
who, bv necessity, go in for cheaper accommo-
dations? There are mighty few doctors that I
know of who can earn $8 per day the minute
thev enter private practice. How long it takes
to make a living after 5-6 years of ardent
study, all of us know. Remember that the
average income of a doctor in the final
analysis is around $3000 to $4000 per year.
Now, the man, the family doctor, who
innocently shoulders the brunt of this economic
question ; the backbone of the medical pro-
fession ; the bulwark upon whom the patient
and the family lean; where does he come in?
He finds his way, day or night, into the sick-
room. No 8 hours or 12 hours of work for
him. There is no special day doctor nor night
doctor. Painstakingly and thoroughly he de-
votes himself to the patient, watching, paving
the way toward recovery ; spending sleepless
nights, thinking of possible omissions or
probable improvements; and when the day’s
work is done he may or may not get $2 to $5
per visit.
As it strikes me, this is no doctor’s problem.
This is a development of the times ; and the
cost of medial care, which one writer claims
to be “unconscionably high” is just a con-
comitant of our present mode of living.
Everything is unconscionably high. Labor,
rent, automobiles, commodities, clothing and
amusements are high. Even dying is high. I
have heard nothing said about the high cost
of being buried. Recently, I saw an under-
taker’s bill rendered to a poor widow who
was left dependent: The coffin (a grey cloth-
covered box with silver plated handles) cost
$550 (some where, some time ago I read that
the actual cost of such a box was $50. Two
automobiles from our Forest Hill section to
the Pennsylvania Railroad Station on Market
Street, a distance of about 3 miles, cost $24.
Incidentals (such as embalming, chairs for
funeral, etc.) were $300. How does that
compare with the high cost of being sick?
Sickness, of course, is no respecter of
persons. Nobody wants it but everybody gets
it. When it does come it is a matter of
necessity, as well as of pride, to have the best.
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
857
When all is said and done, the doctor is
only working for a living. No doctor ever
got rich from his practice and nearly all die
poor. A finger is always pointed at the
financially successful doctor but everybody is
supine or enthusiastic when a business man,
a financier or a bootlegger, gets rich. No one
seems to expect it of a doctor.
Now what can I offer as a remedy (if there
is such a thing as a remedy) ? None of the
many panaceas which has been offered have
solved even the beginning of the question.
Group clinics, pay clinics and health institutes,
or what not, are only experiment stations
which have led us nowhere.
The Journal of the American Medical Asso-
ciation says editorially : “The problem of
providing the public with the best medical
care at a price it can afford to pay has not been
solved in the first 3 years of the 5 year ex-
periment of the Committee on the Cost of
Medical Care. It has not been solved by the
establishment of 60 or more group clinics
in the United States, by the notable success
of one of these clinics or the failure of many
others. It has not been solved by the estab-
lishment of pay clinics in connection with
hospitals, pay clinics established by universi-
ties, or commercial organizations organized
by business men employing full-time physi-
cians. It has not been solved by contract
practice, by health insurance schemes, either
compulsory or voluntary, nor by the individual
general practitioner.”
First of all, it is my impression that the
doctor gives too much of his time to clinic
work without a direct financial remuneration.
No one can afford to spend half his day in
clinics and hospitals free of charge, and ex-
pect to make up the deficiency in the other
half. If he were paid for such clinic work,
such an increase in income would tend to
reduce his price for services to private pa-
tients. Dr. Charles Gordon Heyd made a
similar statement in a recent address aid I
am firmly convinced that the time is very
near when this will come to pass. Why
should a doctor give part of his time free
and then struggle to make a living during the
remaining hours? Why this continuous
hypocritical standard in the name of charity?
Does any one expect it from a lawyer? When
a poor criminal is defended the Courts im-
mediately see to it that his assigned counsel
is properly paid. The state surrounds itself
with all the safeguards at its command, pins
the doctor down to strict and stringent con-
duct, makes laws and edicts to keep him in
line, and then the people expect him to go
out and give most of his time to charity.
State medicine is not the crying need, but
state subsidy of hospitals might be more to
the point. Groups of specialists combined
under one roof may help to reduce the cost
of a complete examination by reason of a
fixed fee for all. The oft repeated demand
that the individual doctor should have a fixed
fee for rich and poor alike is not feasible nor
equitable. This is a question dependent upon
the human equation. It is as old as time and
is only presented as a criticism by the wealthy
and an attempt to place the burden of carry-
ing the doctor upon the middle class.
The Journal of the American Medical
Association says editorially, in reviewing Mr.
Evans Clark’s paper in the Atlantic Monthly:
“Mr. Clark opposes the plan of charging more
to the wealthy than is charged to the poor,
notwithstanding the fact that he does not seem
to have looked carefully into the basis for
such charges. Actually, there is hardly a
professional service available today, including
that of ministers, lawyers, engineers, dentists
and other professions, that does not charge
on this basis. One cannot compare the im-
portance of medical advice to a millionaire
with the price of a box of strawberries. Ap-
parently no one has raised the question as to
why a lawyer will charge a millionaire more
for making a will than he charges a man with
$100,000. when the latter insists on distribut-
ing his money in such a fashion that the will
requires 25 pages more than is required by
the will of the millionaire who has decided to
give all his money to his favorite friend.
After all, the medical profession is becoming
a little weary of suggestions for modification
of its methods and customs by those who have
never taken the trouble to find out those
methods and customs, and the history of the
reason for their existence.”
An outstanding item leading to the reduc-
858
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov. 1931
tion of medical cost is to discourage the
demand and the need for out-of-town con-
sultants. This is of paramount importance
and requires great courage and perseverance.
Every one of you is familiar with the futility
of bringing in, at the slightest provocation,
some favorite out-of-town specialist who does
nothing more than agree with your findings
and propitiates the family — for a high cash
fee. If our community does not harbor men
of sufficient knowledge to help you in your
daily work, then we deserve no credit nor
sympathy. The man who has spent days on
a case and has worked it up from every angle
is certainly more able to make a diagnosis
than a Xew York specialist who comes in
for 15 minutes.
Writing along these lines, Dr. Wingate M.
Johnson speaks, as follows : “The solution
of the medical problem of the middle class is,
after all, simple. It is for every family to
select a physician as its medical adviser.
This man should be selected with great care,
then trusted so long as he is found worthy
of confidence. If the right sort of man is
chosen, and knows that he is the absolute
guardian of the family health and that he is
expected to call in the help of a specialist
or a group of specialists when he deems it
necessary, he will put forth his best efforts
to merit this confidence. His professional
pride, combined with a personal interest in
his patient, will make him more anxious to
get results than any specialists would be. * * *
The modern family doctor is not necessarily
a general practitioner, in the sense that he
undertakes personally to practice all branches
of medicine. Indeed, the modern family doc-
tor is apt to limit his work somewhat ; but he
keeps so well informed along all medical lines
that he is capable of wisely directing those
who trust him. Undoubtedly, many patients
with obscure ailments will be directed to in-
dividual specialists or to clinics ; but the family
doctor is abundantly able to take care of the
great majority of the ailments that arise
among his patients. Such high authority as
the Committee on Medical Education of the
American Medical Association has estimated
that a capable general practitioner can care for
80 to 90' ( of the illness for which people con-
sult doctors. The Committee on the Cost of
Medical Care has found that the famous
‘upper respiratory infections" — colds, influ-
enza. and their near relatives — alone constitute
62% of the usual disabling illness, with the
diseases of childhood and other common ail-
ments to be added. Does this seem as though
there is no more work for the family doctor?
* * * The very conflict of opinions as to
what is to be done to replace the family doc-
tor argues for his continued existence. The
very fact that no satisfactory way has *heen
found to get along without him indicates that
he is an essential part of the medical scheme.
The medical man who is meant to be a family
doctor can never be satisfied with any amount
of success in another kind of work. In the
present stage of medical evolution, this type
of man is successfully adapting himself to
his changing environment. While numerous
lay and medical writers are penning more or
less flattering obituaries of the old family doc-
tor, the modern family doctor is busy making
himself indispensable to as many families as
he can serve.”
There should be a general and frank agree-
ment among the surgeons of every community
as to some uniformity in fees for operations.
Hospitals should conduct their operations in
accordance with their possible income. The
hackneyed idea that hospitals spend most of
their money for the poor can be exploded by
the fact that the poor are being supported
by city pay and private donations ; hotels are
not. Some one facetiously remarked recently
that manufacturers give no automobiles to the
poor. They would if they were subsidized to
do so.
It is altogether destructive to common sense
to build institutions which require vast sums
for their upkeep, with the hope of collecting
such sums either entirely through charitable
donations or by excessive charges. Salaries
and fees for special services in such modern
hospitals are altogether too high for some
favored few, a burden which the patient and
the community are expected to carry. Hos-
pitals should be built and conducted on hotel
plans, the most magnificent of which charge
less than a hospital of equal size and capacity
and give far better service. Modern hospitals
Nov.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
859
are often over-staffed, with little consideration
as to their efficiency and in such a staff the
spirit of politeness and service is woefully
lacking. The idea of a white collar hospital,
so successfully tried in Massachussetts and
now attempted by Mt. Sinai Hospital in New
York, deserves emulation and imitation.
While all these things help materially, they
are not the crux nor a panacea but only a
short step toward alleviation of an existing
condition.
Nurses, in the vast majority, are over-paid.
Consider the requisites of an office assistant in
a big business house, who is able to demand
$50 or more per week. Every one of you
has had an opportunity to judge this. Nurses
should be paid on the basis of a graduate
wage till their fitness and ability entitles them
to a maximum of $7 to $8 per day.
By and large, the high cost of medical care
is not, in my judgment, a problem for which
the doctor is in any way responsible. It is
a product of our economic development,
which is especially indigenous to the United
States of America. We thrive on high prices.
The trades unions want as high a wage as they
can get for their members. The manufac-
turers, in turn, add it to their cost and by the
same token get all they can. Amusement
purveyors charge all the traffic will bear. The
farmer, the middleman and the retailer multi-
ply the original cost till a quart of skimmed
milk costs 18 to 20 cents. And so it goes on,
ad infinitum, until the doctor, as a member
of society with a meager income, finds it also
very difficult to make both ends meet. Of
all the members of any profession, the medical
men, individually and collectively, are the least
avaricious. If there is such a thing as the
high cost of medical care, the responsibility
is not theirs but it is rather a product of this
age, part of our entire economic structure, and
the remedy will, therefore, come only through
readjustment of all of the factors which con-
stitute our present political status.
In short, we come back always to the per-
sonal equation. The demand always creates
supply. If the people want high priced
specialists, high class hospital services, high
priced nursing, it will be furnished to them.
There is no use prating about excessive ex-
penditures and exorbitant charges, when they
themselves believe that the grade of service is
in direct ratio to its cost. The doctor him-
self is, as usual, an innocent victim of all this
cabal and time will so prove it. To para-
phrase those golden words of the “Peerless
Leader” and “Orator of the Platte” — “You
cannot press this crown of thorns upon the
brows of the doctor ; you shall not crucify
medicine upon a cross of gold.”
THE LOVE OF BOOKS
(By James R. Clemens, in the Saturday Review of Literature.)
Happy he
Who, in his home at night,
Finds in his books delight,
And sweet society;
Whilst he who sees no profit in their use,
Will live a fool and die as great a goose.
At my call
Great Shakespeare and his fellows
Stand ready, like my bellows,
For service menial;
Thus kingly do I sit and at mine ease,
Whilst they, when summoned, do their best to
please.
Who pines more
For earthly rank and pelf,
Than good books on his shelf,
Is like a sycamore;
A tree so plagued by density of shade,
That well-intending light shrinks back dismayed.
With a book,
A man is richer far
Than kings and princes are,
Though he no cities took;
For in good books a vein of thought is found,
Which, mined, exhaustless gold yields from the
ground.
860
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
Twenty- five Years
—the money from the sale of Christmas Seals has
promoted:
— the establishment of sanatoriums for treating tuberculosis
• — the finding of tuberculosis in time to effect a cure
— adequate health inspection of school children
— the teaching of habits that help to insure good health
— the bringing of rest, good food, sunshine, fresh air,
medical attention, to sick children
elp CJ\ ight C ubercuiosts
Buy Christmas Seals
THE NATIONAL, STATE AND LOCAL TUBERCULOSIS ASSOCIATIONS OF THE UNITED STATES
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
861
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J.
Entered at the post office at Orange, N. J., as second-class matter
PUBLICATION COMMITTEE
HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J.
EDITOR:
HENRY O. REIK, M.D., P.A.C.S., Vermont Apartments, Atlantic City, N. J.
Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to
receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fact.
NOTE. — The transaction of business will be expedited, and prompt attention secured if:
All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to
The Editor, Dr. Henry O. Reik, Vermont Apartments, Atlantic City, N. J.
All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements,
or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication
Committee, (address above), Newark, N. J.
AUTOMOBILES MORE DEADLY
THAN WAR
Under such a title we read a paper at the
Tristate Medical Conference in December
1930; reviewing the possible causes of so
many automobile accident fatalities and in-
juries, and offering a plan of action on the
part of motor vehicle licensing authorities
which we believed would diminish, at least,
the number of such accidents. In our re-
port to the State Society, in June last, special
attention was directed to this matter and the
House of Delegates passed resolutions author-
izing the appointment of a special committee
to urge upon the Commissioner at Trenton
adoption of the plan proposed. President
Hagerty has appointed the committee and
doubtless action will follow in due time.
While traveling during the summer vacation
period we were interested in the number of
newspaper items appearing in various foreign
cities, giving further evidence in support of
our statement -that a very large proportion of
the so-called accidents are the direct result of
permitting such dangerous machines to be
driven on our city streets and other public
highways by persons utterly unfit to be
trusted with such death-dealing apparatus.
Two of the newspaper items referred to
were of special interest : the first because its
heading set up an association of ideas and re-
minded us of our own previously used title,
and then we found that the content of the
article, as well, bore a strong resemblance to
the line of argument we had developed ; the
second because it was a letter written by a
physician, and, for the first time — in so far
as we are aware — challenged the right to use
the word “accident” in association with many
of these disastrous events.
The Paris edition of the New York Herald
Tribune, of September 9, carried the follow-
ing editorial :
OUR MILLIONS OF JUGGERNAUTS
It is good news that United States Senator James
J. Davis, of Pennsylvania, and John Barton Payne,
Chairman of the Red Cross Society, have given
emphatic warning' of the inexcusable frequency of
automobile killings. The suggestions that Congress
appropriate money for the preparation and ex-
hibition of moving-pictures illustrating the folly
of carelessness and indifference in face of this
constant peril, is excellent, but it does not attack
the evil in a sufficiently radical manner.
Pew people seem to take account of the fact
that today millions of automobiles are rushing
along country roads and through city streets at
rates of speed exceeding that of the ordinary local
railway train. Would the public that tolerates this
abuse of privilege endure for an instant that rail-
way companies should in like manner usurp the
almost exclusive use of our highways and byways?
Why, then, should it be permitted to the owners
of automobiles? It took many years of effort on
the part of the public to compel railway com-
panies to respect human life by adequate pre-
cautions at road crossings. The automobile danger
is greater because more frequent and because it
is due, in innumerable instances, to lack of com-
petence or the heedless m,ania for speed of Tom,
Dick or Harry at the drive-wheel.
Deaths by automobile accidents in the United
States in 1930 numbered 32,500; exceeding by 1246
those of the previous year. Since 1920 such ac-
cidents have increased 149%. Said Senator Davis
in a radio -distributed speech: “I know of no
subject more important to our nation than safety
,as applied to the conservation of life and limb.
During 18 months of the World War, 50,510 mem-
bers of our army were killed in action or died
862
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
of wounds, but during the last 18 months, 50,900
were killed on our highways by automobiles. In
the 5 years from 1916 to 1920 death from highway
accidents totalled 52,760; only 10 years later — from
1926 to 1930 — this figure had mounted to 141,000.
It is estimated that the monetary loss to the
country by traffic accidents in 1930 alone amounted
to mQre than $2,000,000,000."
Modernized warfare is appalling beyond all
power of expression. Must it now be recorded
that peace in a given time takes a greater toll
of human lives than war in an equal period?
On the very same day, the Paris papers
published a United Press report containing
the following statement : “The Labor Day
week-end sustained the loss of 123 lives in
the United States ; of which number, 94 per-
sons were killed in automobile accidents, 12
in aeroplane crashes, 16 were drowned, and
1 death was caused by lightning. During the
same period of time there were, in addition,
reports of 432 persons injured seriously by
automobiles.”
With reference to employing the word
accident in association with automobile kill-
ings. the London Times published at about the
same time a letter signed by Dr. S. F.
Crowther-Smith, reading as follows :
Under the heading Road Accidents our papers
publish long lists of disasters on the road, of
greater or less severity, this state of things being,
apparently, now accepted as an integral part of
motoring. The word, accident, which implies un-
avoidableness, is used to describe these occur-
rences, and thus their true nature is obscured.
In the vast majority of cases they are the result of
definitely dangerous driving, and as it is the duty
of anyone involved in such "accidents” to inform
the police, a brief inquiry on their part would, in
the majority of cases, fix guilt on one or perhaps
both of the parties concerned; prosecution should
follow, and licenses should be cancelled. I am
aware that this is done in obvious cases, but,
in my opinion, the law is not carried far enough,
for in nearly all such cases there is quite definite
evidence for prosecution. By this means offenders
would be gradually removed from our roads, and,
apart from this, the fear of losing licenses after
nearly every “accident” would act as a real de-
terrent.
It is quite possible that coinage and appli-
cation of a word more fittingly describing
such killings — than does the word accidental —
would be helpful in bringing the authorities
and the public to an appreciation of the serious
nature of the situation ; certainly such an
effect might be anticipated if the word chosen
for such use carried with it an implication of
murder guilt on the part of some one involved
in the catastrophe. At the present time news-
papers announce the death of a citizen as the
result of collision of 2 automobiles, and, pos-
sibly, name the occupants of those cars ; or
announce that a child at play in the street, or
an elderly man or woman crossing the drive-
way, was knocked down and killed, by a pass-
ing automobile. If the person killed, or who
later died from injury thus received, happens
to be a citizen of some prominence in the
community, there may be an accompanying
statement that the automobile driver is being
held for investigation “on the technical charge
of manslaughter” ; but we seldom hear of
the matter again. If, on the other hand, the
victim was not well-known, even the promise
of an investigation is not presented. In either
case the published story usually leaves the
reader under the impression that the accident
was unavoidable, and no one was more than
“technically” responsible for the sudden
termination of life for a human being. If,
instead of these flippant accounts conveying
the impression that no one in particular was
responsible for the killing, the newspapers
and official reports would merely change the
form of public statements so that the killing
was made to appear as a murder for which
some one was going to be held responsible,
the affair would assume an entirely different
status ; and we believe that would help very
materially in reducing the number of such
accidents.
We do not mean to say that the persons
killed in such manner are always innocent
victims. Not infrequently the pedestrian who
is thus injured or killed has been guilty of
contributory negligence or worse. So, too,
when the occupants of one car are injured
through collision with another vehicle, the
fault may have been partly or entirely on the
side of the party hurt. In general, however,
that is probably not the case ; the reckless,
irresponsible, unfit driver is apt to escape in-
jury but, inasmuch as the accident results
from his bad driving, and a human being is
by his action deprived of life, he is in fact
a murderer and should be tried on a charge
of manslaughter — not tried for the compara-
tively simple offense of “reckless driving”.
We hope this aspect of the question will
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
863
be laid before the proper authorities for con-
sideration, and we pleadingly call upon every
member of this Society to again read the dis-
cussion published in our Journal of February
1931. pages 14S to 158. and then to use what-
ever influence he may possess toward the
establishment of rules and regulations which
may, to some extent, prevent issuance of driv-
ers’ licenses to persons physically unfit to be
trusted as chauffeurs. You can offer your
services to the committee or act independently,
but, in whatever manner you please, give as
much help as possible toward the diminution
of automobile killings.
PRELIMINARY ANNOUNCEMENT RE-
GARDING POST-GRADUATE
MEDICAL COURSES
The Editor is in receipt of advance infor-
mation concerning the financing of the State
Society-Rutgers Post-Graduate Medical Cour-
ses for the coming year. Because of moneys
recently made available from state funds,
courses similar to those given during the
years 1930 and 1931 will be offered in 1932
at a reduced fee. It appears now that it will
be possible to offer such courses at $15 in-
stead of the $30 fee heretofore charged. The
good news that these courses of instruction,
devised by a special committee from the Medi-
cal Society of New Jersey, and offered to
physicians of New Jersey through the Uni-
versity Extension Division of Rutgers, are to
be had for the very small price of $15 is cer-
tainly something pleasing to be passed along
to our members.
Last year, more than 90 lecturers, promi-
nent in national medical circles, were engaged
to lecture to nearly 400 members in 19 group
centers throughout the state. It has been sug-
gested that this third program shall include
most of the subjects lectured upon last year:
Newer Drug Therapy; Gynecology; Obstet-
rics; Cardiac, Vascular and Renal Diseases;
Pediatrics ; Gastro-Enterology ; Fractures ;
and General Medicine ; but that remains open
for further consideration.
The committee members from both insti-
tutions are now actively engaged with plans
for making the coming season’s offering not
only cheaper but better, and with the exper-
ience gained by 2 years of successful work
and careful observations, it is expected that
the program to be announced next month will
be of exceptional interest.
WORKMAN’S COMPENSATION LAW
In recent issues of the Journal, we have
commented editorially upon the special com-
mittees recently appointed to investigate cer-
tain economic problems which have been dis-
turbing the profession, and in the September
Journal vre directed attention specifically to
the provisions made for study of the Work-
man’s Compensation Law.
Ex-President Sommer has gotten his asso-
ciates together ; gotten each of them to ex-
press his views concerning defects in that law,
or in its application ; has received from mem-
bers of the committee, or from other sources,
suggestions for improving matters ; has pro-
vided each, committee member with material
for study — with a view to an early conference
upon the questions involved; and, as may be
judged from all this, he is, with the hearty
cooperation of every member of his commit-
tee, striving energetically to solve the prob-
lem under consideration. On October 14, Dr.
Sommer entertained the committee, and the
President, Secretary and Executive Secretary
of the State Society, • at dinner in the newT
Waldorf-Astoria hotel, and the group sat un-
til a late hour discussing various features of
the lawr and the many complaints heard.
Among the points most frequently raised,
and which were most thoroughly discussed at
the above mentioned conference, wrere : The
right of an injured employee to choose his
own physician; the injustice of depriving an
injured workman of the care of his personal
physician, by removal to a hospital or clinic
conducted by the insurance carrier; the “lift-
ing of cases’’, and transferring of patients,
sometimes even to places outside the jurisdic-
tion of the Compensation Bureau.
If you have complaints to make or sugges-
tions to offer, nozv is the time to present them
to Dr. Sommer or Dr. Morrison.
864
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
Special Article
TRAVEL TALK
Recent Visit to the Grenfell Mission on the
Labrador
John Hammond Bradshaw, M.D., F.A.C.S.,
Orange, New Jersey
In order to appreciate, to the fullest extent,
Dr. Grenfell’s Medical Mission on the Labra-
dor coast, one must try to visualize what was
the condition of the poor fisher folk who lived
there when Dr. Grenfell, 40 years ago, had his
first inspired desire to come over and render
to them medical and surgical assistance. Prob-
ably there were few places under the Arctic
circle so barren of the comforts, or even the
necessities of civilization. Labrador was, truly
speaking, “the poor relation” of mankind. The
people, a hardy, but God-fearing, population
of fishermen and their families, were located
in sparsely settled and widely separated com-
munities on a wild, barren and rocky coast
some 1500 miles in extent. The high, bare
cliffs, almost without vegetation, dropped pre-
cipitously into very deep water whose summer
temperature even is between 40° and 43°
Fahrenheit. The population was small in
winter but in the summer was largely aug-
mented by a floating population of several
thousand men, from Newfoundland and others
of the more southern provinces, who were
lured by the remarkable fisheries for cod,
salmon, halibut, herring and the seal ; and
further enticed by the fur-bearing native ani-
mals of the interior, in order to trap which one
must endure the rigors of conditions abso-
lutely arctic in character.
Often many hundreds of miles from any
medical assistance, with their little channels or
“tickles” frozen solid during 7-8 months in
the year, the only means of transportation by
dog-drawn “komatik” or dog-sled, they con-
stantly faced blizzards and a temperature
often getting to 40° or 50° below zero, and
one wonders why human beings wished, or
were even able, to endure such hardships.
But, one might as well ask why did the Esqui-
maux choose this and even a more northern
habitat? Why did certain tribes of the great
race of North American Indians travel and
even live in far more northern lands ? The
answer seems to be that all animal life re-
quires sustenance. The Indians hunted the
caribou, the Esquimaux the bear, musk ox
and seal, and the forbears of the present Lab-
rador population found the rivers and sea
simply teeming with salmon and cod ; and on
the land were many animals whose flesh and
fur supplied their needs in a country where
laws and vices (before civilization) were few.
Although the pepole developed an endurance
to hardship almost impossible to imagine, and
became skilled mariners of the deep, where
courage meant life itself, almost unendurable
misery befell them when sickness or accident
became their lot. Strange to say, tuberculosis
was a grim reaper that annually reaped many
a harvest even in that clear, cold climate. This,
one can understand, for they had a diet con-
sisting of fish for breakfast, fish for dinner,
and fish for supper ; vegetables and fruit were
absent, dear, or scarce; a family was fortunate
if it could afford a barrel of flour for the
winter. The story of the vitamins was a
closed book. Hygiene was unknown.
Wilfred T. Grenfell was a sturdy, athletic
English boy. After finishing at medical
school he served as intern in the London Hos-
pital under the great English surgeon, Sir
Frederick Treves. It was a fine schooling for
his future life’s work; because, to the Lon-
don Hospital came the sick, the blind and the
halt of the great and smelly slums of the
crowded city of London. There are no pri-
vate rooms or private patients in that hospital.
The beds are free. It was a wonderful arena
for a man who desired to make his life work
the work of the Master. Sir Frederick told
Dr. Grenfell of the suffering of the sick in
the Fleet of the North Sea Fisheries, and young
Grenfell volunteered to become the first “resi-
dent” physician to several thousands working
the little fishing boats, and earning a bare ex-
istence in a wild world of cold, of wind and
of waves. To catch the right spirit, the ro-
mance, and to appreciate the great hardships
of this job, one must turn to Dr. Grenfell’s
own autobiography. It is more fascinating
than any novel.
The writer does not know how or when the
appeal to “The Labrador” first came to Dr.
Grenfell, but in 1892 we find him crossing the
great Atlantic above “the roaring forties” in a
small sailing ketch that almost foundered on
the way. To the natives, his coming to the coast
was almost “too good to be true”. For heart
stirring accounts and details, one must read
Dr. Grenfell’s own books, which are many.
Battle Harbor at that time was the center
of his work. This little station, which even
now shelters only a half dozen permanent
families, was, we know, the first place of civil-
ization from which Peary sent the announce-
ment that he had conquered the North Pole.
It is also halfway between New York and
London. There, Dr. Grenfell started his first
hospital and from there he answered many a
Nov.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
865
midnight summons to take his faithful dog
team on a 40 or 80 mile journey, and render
succor to some distant sufferer; often facing
an untracked way in an arctic blizzard, and
sometimes arriving in a condition almost as
critical to himself as his patient. In the first
few months he treated 900 patients. Now, one
can visit a whole chain of hospitals and nurs-
ing stations along the Labrador and North
Newfoundland coasts ! Alas ! The hospital
building at Battle Harbor was totally destroy-
ed by fire 2 years ago, and when the writer
faced a cold driving wind and rain, which
almost swamped the little boat that took him
from the steamer "New Northland” to the
shore (as a ship of almost 5000 tons cannot
reach the pier), he found, after clambering
over the slippery rocks, a number of hungry
Esquimau dogs, a few pathetic looking fisher-
men’s houses, and at last, under a shelving
rock, the nursing station which at present is
the sole but important station there of the
“International Grenfell Association”. Since
the fire, there has been no doctor left at Bat-
tle Harbor, but 10 miles further along the
coast one is located at Mary’s River. The
trained nurse in charge at Battle Harbor has
an old (a very old) fisherman’s cottage for
her own home and for her patients who some-
times crowd the little two-floor building to
its very rafters. She was a young girl from
Connecticut and, besides running the dispen-
sary and little operating room herself, she did
all the midwifery and the cooking, nursing
and housework, and managed to keep warm
and cheerful all alone with her one little stove
for the whole establishment. She was young
and sturdy, apparently about 25 years of age
(it is dangerous estimating such things in
feminity). The cold, driving rain, while soak-
ing us completely to the skin before we again
reached the ship, prevented, and this is said
with much regret, taking any photographs or
even exploring with any satisfaction this in-
teresting station.
The hospital at St. Anthony is the pride of
the Association, and they may well be proud
of it. St. Anthony, before Dr. Grenfell’s
coming, had only a scant half-dozen fisher-
men’s houses. Now, we find that the Asso-
ciation has built a modern hospital, designed
by William Adams Delano, the noted New
York architect; an orphanage as big as a
whale (and about as beautiful) ; a dry dock
which is a great boon to the fishermen ; the
Wilfred T. Grenfell School; a clothing store;
and a separate office for managing the Asso-
ciation’s many activities.
It was a cold, windy, August day when we
walked from the ship the short distance to the
hospital. One is at once struck by a very
remarkable sight. There is a flag pole at each
end of the hospital, and on these fly flags at
equal heights; from one pole the English flag
and from the other the American. We are
told that there is no other building in the world
where this can be seen^ as, remember, they
fly here at equal heights! International law
demands that the country of occupation should
have its own flag fly at higher elevation than
that of any other nation. We believe that at
the request of Dr. Grenfell the King of Eng-
land gave the International Grenfell Associa-
tion a special permission to put the “Stars and
Stripes” on a level with the “Union Jack”.
The St. Anthony Hospital is important not
only for St. Anthony and the “I. G. A.”, but
for all these lonely northeastern provinces of
America. At the time of our visit it had 40
beds and 60 patients. Dr. Charles S. Curtis,
from Boston (Harvard and Boston City Hos-
pital), came here to work one summer 8 or 10
years ago and has stayed ever since. His ser-
vice is a most active one. When we paid him
a visit there were 11 patients convalescing (at
one time) from the Albee spine graft opera-
tion; a woman (a pure Esquimau) had just
had an abdominal dentiginous cyst removed,
and as she lay in one of the sunny beds facing
the sea, she smiled at us with her round Mon-
golian face, and her large black eyes spoke
eloquent words, although she did not under-
stand our language. In this hospital they do
tonsillectomies in batches of 10-25 in one
morning. Dr. Phinney (Cincinnati), the ocu-
list of the Association, had just performed
successfully over a dozen cataract operations.
The management has been able to cut the cost
of patients per day down to $2-|-, which, con-
trasted with $6 -f- for private patients in
Montreal, shows good management. One can-
not leave the hospital without noticing the
wonderful cut flowers in almost all the rooms.
It has its own greenhouse, which has most
thoughtfully been donated and supported by
some kind patron of the “I. G. A.” (A Gar-
den Club).
One must not leave St. Anthony without
visiting the orphanage, where about 100 little
waifs are fed, housed and taught. These little
children (some of them Esquimaux) can be
called absolute rescues. When the parents
die — many of the fathers of the orphans hav-
ing died at sea — the children have no place
to go, as it is with great difficulty that other
families can even feed their own. So, in the
orphanage, these little children are given that
nourishment and care which saves them from
tuberculosis, whose toll on the coast is about
60%. Dr. Grenfell has great hopes for the
future of Labrador, through the children.
8G6
JOURNAL OF THE MTOICAL SOCIETY OF NEW JERSEY
Nov., 1931
And he is right. Read these words from one
of Sir Wilfred's diaries:
“I had been summoned to a lonely head-
land. 50 miles from our hospital at Indian
Harbor, to see a very sick family. Among
the spruce trees, in a small hut, lived a Scotch
salmon fisher, his wife and 5 small children.
When we anchored off the promontory we
were surprised to see no signs of welcome.
When we landed and entered the house we
found the mother dead cr. the bed, and the
father dying on the floor. Next morning we
improvised 2 coffins: contributed fiom the
wardrobes of all hands black material enough
for a seemly funeral; and later steamed up
the bay to a sandy stretch of land, bui ied
the 2 parents with all the ceremonies of the
Church, and found ourselves with 5 little mor-
tals dressed in black sitting on the grave
mound.”
But there were other places calling; and
our steamer took us to 2 other stations be-
sides Battle Harbor along the Labrador coast.
At Mutton Bay, the “I. G. A.” is well estab-
lished. Fortunately, there the weather was
fine, and on the bare rocky shores we t\ ere
greeted by a number of sturdy looking Es-
quimau huskies. 1 hese dogs, mostly wolf, have
nothing to do all summer, and their keep, so
essential for their winter’s hard work, is some
drain on their owners’ pockets. They never
get quite enough to eat and the presentation
of a bone is the signal for a free-for-all fight.
One huge, beautiful, snow-white dog came up
to the writer and put his cold nose confidingly
in the hollow of his hand, and waved his big
bushy tail— a tail which is carried as a huge
plume high in the air when the dog is in
action.
While there is no hospital at that point,
there has been established a nursing home and
dispensary under the supervision of a black-
eyed, little, trained nurse who keeps her cot-
tage in a state of spick and span cleanliness
that is a pleasure to see. She had one of the
native girls for her assistant, and she (the
nurse) remains at the station all winter. It
surely must then be bleak and. shut-in to an ex-
treme degree. Like all of the Mission work-
ers, her little face shone with the joy of this
altruistic labor; -keen in the delight of the
service she was giving “without money and
without price”. When questioned, she belittled
all her hardships, and pointing to her small
stove, she said, simply, that she hoped it would
,eep her warm during the coming winter, long
spells of which make it almost impossible to
get any outside help. There, one can buy of'
the natives high Esquimau sealskin boots for
$2.50 (a really great bargain); as hard as
boards when dry and not in use, but a soaking
in warm water will make them as soft and
pliable as kidskin ; and if you wish to wear
6 pairs of socks, they will accommodatingly
stretch themselves and really be most com-
fortable.
Our next stop on the Labrador was at
Harrington, and there we had a surprise;
finding a well equipped hospital. While we
were there, the Mission oculist, Dr. Phinney.
was holding a clinic, and a long line of expect-
ant patients gave evidence of the sincere ap-
preciation of his services, which every sum-
mer he comes all the way from Ohio to do-
nate. The rocks about the hospital were cov-
ered with codfish, drying in the sun. A young
man, a native, who was “making them”, spoke
rather discouragingly about the season’s small
catch and the low price of fish. He got only
$2.50 a quintal, dry (112 lb.), saying that the
labor of “making” them was far greater than
that of catching. He predicted a pretty tough
winter for all hands, and when asked how
much he was able to lay up in cash, gave a
twisted smile and said he never could get
ahead. He was a sturdy lad, about 22 years
of age, with a fine, intelligent face. He was
skilled in all the lore of the coast, navigating
his own boat in such weather as is seen only
above the roaring forties. After September,
the fishing is over. One could only think what
a fine hand he would be on a yacht ; or a most
reliable chauffeur for someone’s car. But.
one of the great benefits bestowed by the
Grenfell Mission on these people is, the send-
ing of just such lads to the States, to indus-
trial schools where they are taught mechanics ;
learning to be electricians, plumbers, masons,
carpenters, etc., with the understanding that
they return to Labrador after such school-
ing (which over 80% actually do), and thus
give their native land the benefits of their
learning and skill. Dr. Grenfell takes the
greatest pride in the fact that the hospital at
St. Anthony, a model of its kind, zuas entirely
built by such labor!
It was our regret that Dr. Grenfell him-
self was, at the time of our visit, high up on
the Labrador coast, in the neighborhood of
Cape Chidley, and so we missed the great
privilege of seeing him face-to-face. He is
now Sir Wilfred, as King George knighted
him for his great services to mankind, in 1927.
Our hope is that most of his very hard work
is over, for it is no secret that he is shadowed
by “the doctor’s complaint”, angina. In fact,
his doctors have ordered him to keep away
from the bleak coast of Labrador all winter.
He is rebellious also, we understand, at the
demand that he refrain from taking his morn-
ing plunge from the forecastle of his hos-
pital ship. One can readily understand that
this is wise advice, when one knows that the
temperature of the water, on the Labrador,
ranges from 40° to 43°; in fact, we were told
that it is so cold that even these hardy fishers
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
867
never learn to swim, and when they fall from
their boats, if no help is at hand they quickly
drown. (The temperature of the water is
32° in winter.)
When over 40 years of age, Sir Wilfred
“met his fate” while crossing the Atlantic one
summer on the Mauretania, and Lady Gren-
fell, besides abetting and encouraging him al-
ways in his great work, has presented him 3
splendid children — 2 boys and 1 girl — the
elder boy entering Oxford this fall.
One cannot do better, in closing this long
paper, than quote the “Cold Facts” printed
by the Association :
“Fifteen hundred miles of coast line, mostly
populated by Anglo-Saxons, is served by 4
hospitals, 7 nursing stations, 4 hospital ships,
1 supply ship, 14 industrial centers, 1 orphan-
age, 4 summer schools, 4 winter schools,
boarding and day, 12 centers for distribution
of new and second hand clothing (all clothing
paid for by labor), haul-up-slip for steamer
and schooner repairs, 3 agricultural and ani-
mal husbandry stations.
Last year: 14,000 patients treated by hos-
pitals, hospital ships and nursing stations, 500
children were cared for in the schools and
orphanages, 2500 women and convalescent and
disabled men and boys were given employment
/through the industrial department: 40 schoon-
ers and steamers were repaired in the haul-
up-slip. A year-round staff of 61 includes
surgeons, nurses, teachers, industrial and so-
cial workers. In addition, there is a volun-
teer staff of 100 during the summer months.”
Let it be added that this volunteer staff
volunteers not only time and services, but
pays all expenses (which come to about $550
for the season), and that there are sufficient
volunteers of both sexes so that the Grenfell
Association is able to select only the highest
class of young people. These workers gladly
do any service. For example, returning on
our ship were about a score of collegians who
had termed themselves (in great pride)
“Waps” because they had spent the summer
digging a milelong pipe-line at Cartwright.
When asked if they met with any rock, one
of these boys answered — “We met absolutely
no dirt; and digging a trench 6 feet deep (be-
cause the frost goes 4 feet in winter) through
solid rock for 1 mile in length is not a lazy
man’s job!” Out of 800 applicants this year ,
about 40 were chosen.
The young women who come up here for
the summer work, giving up a “good time” at
Newport, Bar Harbor, or I.ake Placid (pay-
ing over $500 for their job), also have no
sinecure. Hard domestic service may be just
sprinkled in for luck. But, as before remark-
ed, their faces shine with the joy of service.
As a final word, let it be said: To few men
on this earth has been given the vision, the
rare initiative and the immense joy and sat-
isfaction to accomplish, in the name of the
Master, so much for his fellowman as has
been given to God’s true servant — Sir Wil-
fred T. Grenfell !
NOTE : To some it may be of interest to know
that all information about the International Gren-
fell Association can be had at 425 Madison Avenue,
New York City, where thick, warm clothing is
much needed, new or second hand, and will be for-
warded to Labrador at the Mission's expense.
Should one wish to verify these facts, and see the
work, the Clarke Steamship Company, 10 Dominion
Building, Montreal, Canada, will send folders tell-
ing about the delightful summer cruises to The
Labrador.
Medical Ethics
SUCCESS
John Hammond Bradshaw, M.D., F.A.C.S.,
Orange, New Jersey
“It is not our cheap victories in life that
measure our status , but how we meet its
vicissitudes.”
This subject has been written about so of-
ten that it is almost trite. But the man is rare
who denies its desirability. The definition of
the word differs with different people and in
different lands ; and when it is obtained one
may not know what to do with it.
To a doctor, the word is generally meant
to indicate a large practice and an abundance
of this world’s goods. And yet, many of us can
think of several doctors who had attained to
this very state but went down to their graves
“unknown, unhonored and unsung”. A suc-
cessful life implies more than the acquisition
of money. Did not A1 Capone scoop up a
nice little pile? In his special line, his friends
considered him a little Napoleon of Success ;
nor was his downfall only measured by his
crimes. If he had never stepped outside the
law, his psychology alone, in clue time, would
have laid him low. A whole lot depends upon
what standard of success we seek to obtain.
Sir Thomas Lipton was for 30 years the
unsuccessful seeker for the America’s cup,
the blue ribbon of the whole yachting world.
Yet, in defeat he was successful. By an un-
usual complexity of personal talents and quali-
fications. Lipton drew all men to him and died
a successful man.
Once in several thousand years, a very great
man is born. Was Christ successful? Those
who saw Him die on the cross would not have
said He was. Emerson, “the wisest Ameri-
can”, often lacked the comforts of this life,
and when years ago he lectured in the town
where the writer lives, just 18 people attended
8G8
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
his lecture. Was Emerson a success? Read
now, after all these years, a few of his say-
ings. Like wine, they improve with time.
“Orientalism has long thought it majestic to
do nothing; the modern majesty consists in
work.” (Italics mine.) “Let him know that,
though the success of the market is the re-
ward, true success is in the doing.” (Italics
mine.) And, speaking of a successful man,
he warns as to the perils that attend success.
Naturally, we all consider Edison one of
the world’s most successful men. But his most
unusual characteristic was his utter forgetful-
ness of success when his mind was at work.
Never lived a man to whom money meant so
little if it did not enable him to better com-
plete some one of the objects, ambitions or
ideas that, like a southern tornado, were al-
ways swirling in his mighty head.
Our truest success, however, comes when,
in spite of defeat, we rise superior to our
vicissitudes, be they bodily or material things!
Esthetics
MUSICAL MATTERS OF INTEREST
TO PHYSICIANS
During the past 5 years we have used this
department of the Journal several times for
discussion of music as related to medicine ;
that is, as of therapeutic value in the treat-
ment of disease, especially nervous affections,
or, as of interest or importance to the physi-
cian personally, in the sense of recreation,
avocation or mere artistic enjoyment. This
month we have the opportunity for presenta-
tion of 2 items that we stumbled upon during
our summer vacation and which we hope will
be of sufficient interest to our readers, or of
actual scientific value to a sufficiently large
number thereof, to justify publication. The
first item concerns a curious natural phe-
nomenon and some related laboratory experi-
ments that were reported recently to the Brit-
ish Association of Scientists, at its annual
meeting, in London, under the title of
“Musical Sands’’ ; the second, concerns “Re-
produced Music” as we know it from the
phonograph or radio, and deals with the
science of acoustics and the physiologic func-
tion of hearing, and should, in consequence,
be of interest at least to our otologists. In
both instances we will quote freely from the
London Times of September 26.
Musical Sands
A demonstration of the properties of
musical sand was given in Section A (Mathe-
matical and Physical Sciences) of the Brit-
ish Association, by Mr. C. Carus-Wilson, at
the session on Friday, September 25, 1931,
which drew a large attendance of members
from other sections to observe the display.
In a preliminary paper the demonstrator had
pointed out that for many centuries travelers
have spoken of the existence of sand which,
under favorable conditions, mysteriously pro-
duced music. Such musical sands have now
been discovered in many places and reported
by scientists ; as when Professor Bolton and
Dr. Julien reported through the Smithsonian
Institute, in 1884, the finding of musical sand
at no fewer than 74 localities along the At-
lantic Coast of the United States. Pie had
personally found such sands at Studland Bay,
England, and in many other places.
“It would appear that the effects produced
by the accumulations of loose sand were
similar in all cases, and differed materially
from the sounds emitted by the musical sand
of beaches when struck or agitated by artificial
methods. He believed that they were due to
the rubbing together of millions of clean and
incoherent grains of quartz, free from angu-
larities or roughness. Though the vibrations
emitted' by the friction of any 2 grains might
be inaudible, those emitted from millions
approximately of the same size would give
an audible note.
Mr. Carus-Wilson filled a small bowl with
ordinary sand, and struck it with a child’s
nine-pin, demonstrating that it emitted a
mere crunching noise, similar to that obtained
by scratching the irregular-surfaced binding
of a book. Upon doing the same thing with
musical sand he obtained a musical note, as
he also did when scratching the surface of a
binding which had minute and regular cor-
rugations. A pen-point rubbed at a certain
angle upon smooth glass, and held loosely, was
shown similarly to emit an even squeak ; it
did not produce any similar sound when
rubbed across matt glass. A less bulky plunger
in the musical sand emitted ‘ a higher note,
and by adding bulk to the plunger even at the
opposite end (by screwing on a bed-knob), it
was shown that the note was deeper. Mr.
Carus-Wilson declared that with a basin of
musical sand and a rolling-pin it was possible
to obtain a noise like the baying of a dog.
Glass, china, and bamboo plungers, gave good
results; cork and* rubber, negative results.
The vessel was also important. A wooden
cup was very loud, and an enamelled thimble
gave a decidedly high-pitched note, while the
inside of half a rubber ball gave no audible
reaction.
The demonstrator remarked that if one con-
tinued plunging musical sand for a short time
it became silent, and was “killed”, probably
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
869
because some of the grains were ground to
powder, which acted as a cushion against the
vibrations. He illustrated this phenomenon
bv mixing flour with the musical sand, which
was then “killed”. The shape of the vessel
was also important, and he showed how pour-
ing the sand into a flour-pot-shaped vessel
made it compact, so that it lost its incoherence
and the musical note was not produced.”
Reproduced Music
In the Entertainment Section of the Lon-
don Times, September 26, 1931, an article
prepared by an unnamed correspondent re-
viewed the results so far attained in efforts
to reproduce music faithfully over an exten-
sive radio dissemination, the writer being
particularly concerned about the quality of the
reproduction. With elision of the first para-
graph only, we reprint the Times’ article:
It is perhaps advisable, to prevent mis-
understanding, to remind the reader of some
of the fundamentals of musical sound. Sound
consists of air vibrations, and the simplest
sound is a “sustained pure note”. This sound
is seldom heard outside the laboratory, but a
near approach to it is sometimes got from the
lower notes of a flute played pianissimo , or
the open diapason stop of an organ. Such
a note is completely described by 2 character-
istics : its strength and its pitch. Pitch de-
pends simply on the number of vibrations
per second, or “frequency” as the physicist
calls it: middle C of the piano has a fre-
quency of about 250 hertz — that is, the middle
C string vibrates 250 times per second. The
lowest and highest notes of the piano cor-
respond to about 20 and 4000 hertz, and each
octave is of exactly twice the frequency of
the corresponding note below.
A much more common sound is the com-
plex note. This — such a note as that of a
violin or clarinet — comprises a pure note with
the addition of “harmonics” : notes of twice,
three times etc., its frequency. The lowest
note is usually referred to as the fundamental,
and governs the apparent pitch of the sound,
while the relative strengths of all the various
components give the “colour”, timbre, or
“quality”. More complicated still is the
chord, in which several complex notes are
mixed, so that the harmonics are no longer
notes just 1, 2, 3, or more octaves above the
fundamental, but have frequencies bearing
fractional ratios — 3/2, 5/2, 4/3, etc. Lastly,
there are the notes not sustained — the drums,
explosions, the sounds of speech, and so on ;
which are defined not only b}^ the character-
istics above mentioned, but also by the rate at
which they start and fall again to silence.
It is important then to consider what
changes may occur in these various types
of sound when they have passed through
the complex series of conversions which lead
them from the studio to the listener’s ear.
J ust how many are these conversions is not
generally realized ; by way of an example,
the energy passing through the writer’s wire-
less receiver — a typical modern apparatus — is
altered in form no fewer than 25 times be-
tween its entry as an ether wave and its exit
in the form of sound. At any one of these con-
versions there may be an undesired change,
affecting the quality of the final result; and
it is the duty of the radio and acoustic en-
gineer to see that this does not happen.
Perhaps the most widespread defect at the
present time is what the acoustic engineer
calls “restricted frequency range” : the ex-
treme bass and treble notes are not reproduced
so strongly as the middle register. As has
been said above, the piano’s lowest note has
a frequency of about 20 hertz, and the bass
instruments of the orchestra go down to
about the same pitch. Some grand organs
go even lower. Here, there is something of
a paradox ; for the average human ear can-
not hear below 30 hertz — a fifth above. It
would seem at first sight that the lower notes
are useless. But this is not so, because these
notes, as played, are complex, and even if the
fundamental is too low to be heard, the
harmonics produce their effect.
It is a curious and very important fact that
if the fundamental of such a complex note is
completely removed in the course of repro-
ducton the ear still persuades the brain that
it has heard it. This is the salvation of many
reproducing instruments, for the casual ear
credits them with powers that they do not
possess. It is a most interesting experiment
to reproduce, say, a double-bassoon note of
about 60 hertz — 3 octaves below middle C —
and arrange the apparatus so that the lowest
note it will reproduce is first 50, then 100,
and then 150 hertz. Although the first change
abolishes the fundamental- and the second the
lowest harmonic also, the pitch seems still the
same. It would appear from this that the-
lowest notes need not, after all, be reproduced
— -and, in fact, the apparatus of a few years
ago, and some modern apparatus, does not re-
produce them. But this is a fallacy. Al-
though the pitch is unaltered, the tone-colour
suffers. The effect is a reedy or tinny quality
which is most offensive to the keen ear.
The result of the defective treble range is
6f the same nature. The highest note of
the piano (C4) is of about 4000 hertz, and
is of about the same pitch as the highest
note usually played on the violin. But if,
as is sometimes the case, the apparatus stops-
870
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
reproducing at this point, the harmonics are
lost; piccolo and violin sound alike. The
highest note audible to a young ear is usually
2 octaves above this, in the neighborhood of
16.000 vibrations per second; but advancing
years dull the ear to these very high notes. It
is usually considered sufficient, even among
purists, to reproduce up to 8000 or 10,000
hertz. Apart from the actual limits of the
frequency range, there may lie other troubles.
There may be lack of balance — a progressive
favouring of bass or treble within the range
reproduced — or some few notes in a partic-
ular compass may be over-accentuated.
The second great fault which must be
avoided is called distortion. It is a change
in tone-colour. Strictly speaking some of
the defects discussed in the last section should
come under this heading : the decrease or loss
of the fundamentals of low notes or the
harmonics of high ones, due to restricted fre-
quency range. But the defect to which the
acoustic engineer especially applies this name
is the introduction of false harmonics. The
result is to make a pure note complex, and
to change a complex one always in the direc-
tion of greater harmonics. Every reproducer
has a limit of loudness beyond which this
trouble will occur; so that sometimes it may
be due to faulty usage of apparatus which is
quite satisfactory when not over-driven.
Lastly, comes the question of loudness. It
does not seem yet to be fully realized that
to get the proper effect of good reproduction
it must sound of the same strength as the
original. Here one must explode a fallacy.
One is often asked: “How is it possible to re-
produce a large orchestra in this small room?
If it were here, playing at full strength, the
noise would be unbearable. Yet you say that
one must not reduce the loudness if one wants
true results.” The reply is really simple.
Consider a person in the Middle of Queen’s
Hall. The sound of the orchestra, fortissimo,
strikes his ear at a certain pressure. Then
that same pressure must be made to strike
his ear when he sits a few feet from the re-
producer in his home. At Queen's Hall, per-
haps, he gets a millionth of the total power
within the hall ; at home, perhaps, a thous-
andth ; hence the total power of the repro-
ducer may be very small compared with that
of the orchestra. But to get the right effect,
the power delivered to the ear must be the
same.
A final word on reproduction in general.
If the frequency range were ample and dis-
tortion nil, so that every note were exactly
reproduced; and if the power be sufficient —
still, can the purist be justly satisfied? Here
Ave touch on the elusive subject of atmosphere.
The reproducer gives us what the microphone
heard — the effect on a one-eared man hung
from the roof of the hall — and in our room the
sound comes all from one point ; we cannot
prove by hearing that the violins are still on
the left and the basses on the right ; we can-
not see the conductor’s white carnation. So
that one must admit a difference. But is the
difference a defect? There are some who
consider that these last things are distractions,
and who prefer the solitary peace of an arm-
chair in a dim room, with nothing but the
music to think of.
It is interesting now to see how near the
ideal we can get in practice. Broadcasting
is variable. Such transmitters as the new
regional stations of the B.B.C. in England,
and some half-dozen or so modern ones
abroad, are \ferv good indeed when they send
a performance from a not too distant studio
or hall Sometimes a program is sent over
an imperfect telephone line, which restricts the
frequency range. Sometimes an individual
performer will come too near, or go too far
far from, the microphone. But as a rule
there is never a lack of a program which is
practically perfect as it leaves the transmitter.
But the best transmission from the broad-
casting station will not give good reproduc-
tion without corresponding care in the re-
ceiver. Only a few people know enough or
care enough to insist on first-class quality of
results; and since it costs a little more to make
a receiver first-class, therefore the second-
class — and worse — sell in larger quantities,
which exaggerates the difference in cost. The
finest apparatus within the writer’s knowledge
has never been put on the open market, for
just such reasons; but there is, nevertheless,
quite a good selection, and it is now possible
to build to order, even if not profitable to
manufacture in quantity, a receiver which will
reproduce all notes from 40 to 8000 hertz, or
higher, with no perceptible distortion, and
loud enough for any domestic purpose.
Collateral Reading
WILL OTHER WORLDS AFFECT OUR
HEALTH?
From a Parisian paper, Le Comoedia, we
have abstracted part of an interesting address
by an eminent French scientist, M. Leon Le-
cornu. upon the possibility of other universes
affecting the inhabitants of this terrestrial
globe ; as follows :
“Have the ether waves any influence on our
health ?
It is certain that this is the case with light
Nov.. 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
S 7 1
and heat rays, and with ultra-violet rays, as
well as the x-rays and the alternating currents
used in medicine. As for those used in wire-
less and in radio, it would appear that such
influence, if it exists at all, is absolutely neg-
ligible, for even at a very short distance from
a transmitting station the energy received is
too feeble to act effectively. We need not,
therefore, suffer any anxiety on this account.
To hear at all distances is already possible,
but we wish to go further and realize tele-
vision. The moving-picture became a ‘talkie’ ;
now we have the reverse problem of turning
telephony into television, which we have al-
most solved. The day will come when, com-
fortably seated in a closed room, we shall see
the inhabitants of the antipodes, as well as
hear them speak.
The reverse of the medal is that the en-
thusiasm roused by great discoveries now
scarcely moves us. Besides this is the incon-
venience, inherent in all relations at great
distances, that, as with Balzac’s wild ass’ skin,
the surface of our planet seems to have
shrunk in proportion to the satisfaction of
our desires. It is true, of course, that we
know only its outer skin. Below that, we
should have to travel some 4000 miles before
reaching the center. Here lies the kingdom of
Pluto, about which we possess only the
vaguest information. Jules Verne, Wells, and
others have made imaginary trips into these
mysterious regions. To attack the problem
scientifically we need new processes of in-
vestigation at a distance.
In the other direction, that is, away from
the earth, we are much better served. Every-
thing indicates that about 300 miles up there
is an ionized layer that opposes the passage
of wireless waves, and so, increases the hor-
izontal distance that they will carry. Above
this begins the void occupied by distant celes-
tial bodies that the telescope and spectroscope
enable us to study with daily increasing pre-
cision.
But they say that man will never be satis-
fied with his attainments. The balloon, the
airplane, require the air to sustain them. On
the other hand, the rocket, thrusting out be-
hind it a train like a comet’s tail, is theoret-
ically able to propel itself through empty
space. We may thus embark in a vessel pro-
vided with rockets and visit the moon, which
obstinately shows us always the same face,
and then push on to Mars, to- Venus, and far-
ther still — always farther. This new mode of
locomotion is already baptized : it has been ,
dubbed astronautics. The calculations have
been made ; it remains only to find the neces-
sary capital. We are not told whether the fu-
ture company will sell round-trip tickets !
Meanwhile, if the investigator, instead of
directing his attention to the infinitely large,
turns toward the infinitely small, he finds
there other marvels. In every atom he divines
a central star called the nucleus, surrounded
by a swarm of planets, obeying, in their revo-
lutions laws very different from those of celes-
tial mechanics ; nevertheless he believes, as a
fundamental dogma, that here also the law
of the conservation of energy holds. This is
not all. The nucleus, despite its prodigious
smallness, is susceptible of spontaneous, pro-
gressive decomposition. This is the case with
radium, which we have been able to attack
with radiation that is sufficiently penetrating.
It has been shown that this microcosm con-
tains formidable reserves of energy which in
the future we may be able to utilize, and this
would be the greatest industrial revolution
that humanity has ever known. Will it make
us happier? That is quite another question!”
In Lighter Vein
See America. First
“How was the scenery on your trip?’1’
“It ran largely to tooth-paste and smoking to-
bacco."— Louisville Courier- Journal.
Didn't Do Right by Our Venie
“Could one refer to the Venus de Milo as the girl
who got the breaks?’’ J. C. M. inquires.
Why not? It’s an ‘armless joke. — Boston Trans-
cript.
Pass the Potato-Masher
“How much are eggs?”
“Fifty cents a dozen — 30 cents a dozen for crack-
ed ones.”
“Good — crack me a dozen.” — Arart Hem (Stock-
holm).
No Sun-Bather
An Eskimo lady exclaimed, with a smile,
“I do not pretend to the latest in style,
But you’ll have to admit that up here in the Cold
I never wear bathing-suits you could call bold.,’’
— Washington Star.
Scooting Time
The village doctor was taking a friend for a
trip in his car.
“I say, look out!” cautioned the passenger.
“You're doing over 60 miles an hour!”
“Don’t worry about that”, chuckled the doctor,
“I've got the village policeman in bed with rheu-
matism.”— Manchester Evening Chronicle.
Life’s Darkest Moment
Two attorneys, one decidedly glum of counten-
ance, met on the street.
“Well, how's business?” the first asked of the
dismal one.
“Rotten!” the pessimist replied. “I just chased
an ambulance 12 miles, and found a lawyer in it."
— American Legion Monthly.
872
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
Lighthouse Observations
DIAGNOSTIC RELATIONSHIP OF PHYSICIAN
AND DENTIST
Two interesting articles dealing with this ques-
tion having fallen recently into our field of vision,
and having had personal experience with focal in-
fection permitted to run its course too long a time
before giving proper attention to the teeth as a
possible source of disease in remote parts of the
body, we offer abstracts of those papers for con-
sideration.
At the Annual Meeting of the New Hampshire
Medical Society, Otis M. Littlefield, Past-President
of the New Hampshire Dental Society, delivered
an address entitled “Some Phases of Dentistry
Which Should Concern the Medical Practitioner’’,
in the course of which he said. (New England
Jour. Med., 203:479, Sept. 4, 1930):
“Probably the most important phase of dentistry
that concerns the medical practitioner is the as-
sociation of dental disease with systemic distur-
bances. Many articles have been written and
several explanations have been offered to show
the pathologic sequences in focal infection but I
dare not say which one is correct or that any one
so far offered is correct, yet all may be correct.
However, the point is now reached when clinical
evidence is established sufficiently to prove that
dental disease does present a focus of infection.
As medical men, responsible for people’s health,
or restoration to health, you are deeply con-
cerned with any contributing cause of disease. As
dentists, being responsible for maintaining dental
health or eliminating dental disease, we are just
as deeply concerned in relieving or preventing, if
possible, chronic infection in our field.
Dental focuses of infection are principally in the
alveolus, that is, the damage comes through a
chronic low-grade infection of the alveolar process
either at the apex of the tooth roots or around the
surface of the roots between the apical area and
the gingival or gum border. The reason, of course,
that this distinction in locality is made, is that in
general a different disease attacks each area.
Peri-apical infection is usually the result of de-
vitalization or extirpation of the dental pulp which
in either case cuts off a considerable amount of
nutrition from the tooth. Parietal infection, or in-
fection around the root not involving the apical
area, is usually the result of so-called pyorrhea. In
this process of disease, part of the nutrition is de-
stroyed but no doubt to a lesser degree than
through the loss of pulp. Pyorrhea is always a
chronic disease and while in one form it pro-
gresses faster than in another, it is marked by an
insidious, persistent, rarefying or condensing os-
teitis, and even though there is drainage through
the pocket formed between the alveolar process
and the tooth, it is difficult to believe that such
a disease process is not at times a contributing
factor of focal infection.
Peri-apical infection presents an osteitis, either
rarefying or condensing, but the etiology in this
condition is such that there is apparently a slight-
ly greater defense built up to localize the infection.
Probably the most common evidence of this de-
fense in the chronic type is represented by the
formation of a granulation tissue, termed accord-
ing to dental nomenclature as a granuloma. At
times this granuloma is inactive as a process of
infection but yet it may at any time break down
and become an active abscess (not acute, neces-
sarily, but an active chronic abscess). Peri-apical
condensing osteitis is very difficult to diagnosis, but
from the standpoint of systemic disease is a dan-
gerous lesion. It is dangerous because the blood
supply becomes very limited and the defense is
almost entirely cut off. While in some cases of
peri-apical infection there is drainage through the
open root canal, or through a fistula, absorption or
extension into the blood stream is abated but par-
tially. With no drainage to the surface, infected
bone is a very vicious enemy to the human or-
ganism.
Alveolar abscesses may enlarge or coalesce and
form cysts but these are usually walled off by a
layer of bone and are dangerous in that they
may develop into malignancy, osteomyelitis or frac-
ture.
Another disease of the alveolus that the medical
and dental professions are jointly concerned in,
is the fusospirillary stomatitis, or commonly called
Vincent’s infection. Now, I am convinced that this
disease, if at all advanced, and perhaps in every
case, should be handled by the physician. He
may give intravenous treatment, take a blood
test and observe the patient’s general reaction,
but the patient should be referred or sent back to
the dentist for oral treatment. This is being done
in the larger hospitals with fairly successful re-
sults. With intravenous treatment there is less
liability for recurrence, and in some cases the
blood test reveals a specific infection. The local
treatment consists of gently removing the exudate,
cleaning so far as possible all debris from the
teeth, and applying spirocheticides. Oxidizing
agents are prescribed for home use. Sodium per-
borate is probably most commonly used.
Dentistry for children presents a problem to
both professions, principally in the handling of
abscessed, deciduous teeth. We, as dentists, are
concerned in the normal development of the jaws
and dental arch. We realize the importance of
retaining these deciduous teeth until it is time for
the permanent teeth to erupt in their place. Yet
these teeth are often bothersome to the child,
and if that child is showing malnutrition or mal-
development. cervical adenitis, symptoms of chorea,
or in any way his general health is affected and
draining of the abscess fails to give proper relief,
it is considered good practice to take the lesser of
2 evils and extract the teeth. The policy of the
public health clinics generally is to extract all ab-
scessed, deciduous teeth, but, of course, that is a
public clinic where a careful watch or check-up
on the child is impossible.
Our chief measures in preventive dentistry are
to prevent advanced lesions by frequent examina-
tion, possibly more thorough examination to lo-
cate and properly fill small cavities, to select care-
fully our means of restoration in order that they
will not be the cause of any further disease. Not
long ago, it was common practice to devitalize a
tooth to provide a support for a bridge. That is
not done today; in fact, it is rare that a vital
pulp that can be kept vital is disturbed. When
we remove that pulp, even if it is done under the
most painstaking method, we are making the tooth
a potential source of alveolar infection. It is ex-
• tremely rare that a dentist today attempts to
treat an abscessed tooth. We realize that it is
almost impossible to maintain thoroughness Sn
asepsis in the average dental office, so we are com-
pelled to turn to antisepsis and our results are un-
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
873
satisfactory in too high a percentage of cases to
warrant any attempt at devitalization except in
very rare instances.”
At the Annual Meeting of the Old North State
Medical, Dental and Pharmaceutical Society, held
in Wilmington, North Carolina, June 18, 1931, Dr.
J. S. Perry read a paper entitled “Cooperation of
the Physician and Dentist in the Diagnosis of
Disease”, and from his remarks we quote as fol-
lows:
“There seem to be, according to Hayden, 4 types
of dental infection associated with systemic dis-
ease: (1) Chronic peri-apical infection of pulpless
teeth; (2) pyorrhea alveolaris and pus pockets
around partially erupted teeth and reconstructive
appliances; (3) chronic pulp infection in vital
teeth; (4) residual alveolar infections after tooth
extraction.
Teeth with infection around the apices may
cause, with little or no warning, involvement of
the arteries, kidney and heart muscle. This type
of infection is the result of devitalization or ex-
tirpation of the dental pulp, and culminates in
cutting off a large amount of nutrition from the
tooth. When the infection is around the root, not
involving the apical area, the condition is the re-
sult of pyorrhea, a disease the presence of which
should be determined by the dentist. I further
believe that, though we know but little about this
subject, before sacrificing every devitalized tooth,
there should be eliminated every other possible
focus of infection. Blum advocates the removal
of these teeth only as a last resort and not without
having first examined and treated every diseased
condition in other parts of the body. Exceptions to
this are often made to relieve neuralgic pain
caused by malposed teeth. And even in this event,
removal of infected and impacted roots often fails
to give immediate relief.
There are sometimes found around partially
erupted teeth, pus pockets. These, as well as typi-
cal cases of pyorrhea, may by bacterial absorption
cause much trouble.
The removal of an infected tooth does not always
get rid of the alveolar infection, which sometimes
continues long ■ after the extraction; a fact that
should remind both dentist and physician that
roots of teeth are not always the prime source of
the trouble. This residual infection, which has
long baffled medical science, has been responsible
for a number of vague systemic involvements. For
detection of these abnormalities of the teeth, the
physician and dentist rely upon radiographic find-
ings.
The presence of granular tissue about the roots
of teeth often destroys and sterilizes inflammatory
tissue. Under these conditions the teeth appar-
ently affected give no pain. This granular tissue,
though at times inactive, may at any time break
down and become an active abscess, not acute nec-
essarily, but an active chronic abscess. It is here
that the dentist realizes other means of diagnosis
and resorts to transillumination, vitality tests, per-
cussion and sensitiveness to heat and cold.
The diagnostic value of dentistry as related to
the laryngologist is plainly seen in sinus infection
resulting from a peri-apical abscess. In empyema
of the antrum, the removal of a tooth for diag-
nostic or therapeutic purposes has proved super-
ior to perforation of the canine fossa.
In the field of ophthalmology, focal infection
plays an important role in causing iritis, uveitis
and neuritis.
In the realm of general surgery, duodenal ul-
cers, appendicitis, pyelitis, osteomyelitis and Vin-
cent’s angina, may be traceable to affected teeth.
The dentist has a peculiar diagnostic relation-
ship to internal medicine, about which I am more
concerned than any other branch of the science,
because of the close alliance of this phase of medi-
cine with dentistry in affording a common meeting
ground for the study of infectious diseases. Among
these diseases of obscure origin, especially infec-
tions in which streptococci are found, is a type not
referable to peri-apical abscess. Rheumatic fever
is more often attributed to infected tonsils and
sinuses than to diseased teeth.
Chronic infectious arthritis is a pathologic con-
necting link between medicine and dentistry. It
has been definitely proved that the streptococci
in root abscesses are culturally and biologically of
the same strain as those found in the blood of
polyarthritic cases, produced by injection of the
streptococcus prepared from abscessed teeth and
blood. These agglutination and absorption tests
have been successfully performed by Miner on the
rabbit. He states that he has cultivated strep-
tococci from 62% of patients with acute infectious
arthritis.
There is also a type of arthritis that has been
somewhat a puzzle to many of us. This is known
as osteo-arthritis and is non-infectious. This form
of arthritis involves the bone and cartilage instead
of the synovial membrane and capsule of joints
as does infectious arthritis. Osteo-arthritis seems
to be more often encountered in elderly persons,
and occurrence of this disease has led me to note a
number of toothless mouths in patients who have,
with disappointment, looked forward to extraction
of their teeth as a cure for arthritic pain. It has
been shown by many investigators that this type
of arthritis is non-infectious and cannot be met
by the extraction of the teeth.
Abscesses of the lung not only occur after pneu-
monia and from operations about the nose and
throat, but after the removal of teeth. These ab-
scesses could be prevented to a great extent by
proper mouth hygiene.
In considering the relation of the teeth to some
other medical conditions, our attention is called
to stomatitis of mercury poisoning, and the lead
line of the gums in lead poisoning. These chemical
intoxications are often first seen by the dentist
who, because of early recognition, can render a
valuable service by reporting the case to a phy-
sician.
Among the kidney diseases traceable to peri-
apical abscesses are pyelitis and pyelonephritis.
The cardiac diseases, myocarditis and endo-
carditis, are frequently seen in private as well as
hospital practice. The infections of the endo-
cardium are often of the streptococcal origin.
These infections are closely, related to those of
multiple root abscesses.
Graves’ disease (hyperthyroidism") is often bene-
fited by the removal of infected teeth; a fact,
that has well confirmed the relationship between
this disease and focal infection.
In fact, the entire relationship between focal in-
fection and internal medicine is of such impor-
tance as to draw from an eminent practitioner
the statement that nine-tenths of modern practice
of medicine is devoted to "searching for focuses of
infection.
In the opinion of Dr. Joel T. Boone, the dentist
as a specialist should be called into consultation
as a routine procedure, as is the roentgenologist,
bacteriologist, urologist, pathologist and ophthal-
mologist. He further states that the physician, in
his attempts to diagnose and subsequently treat
disease conditions, fails to practice honestly and
874
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
scientifically if he does not consider the oral cavity
as the nrira'e source of trouble in a Ions' trend of
symptoms and disease entities.
The diagnostic relationship of the dentist to the
physicians in hospitals, is of such paramount im-
portance as to necessitate the presence of a Dental
Director on the staff of a well regulated hospital.
Dental interns have also been appointed in many
hospitals, and their work should be on a par with
that of the medical intern.”
Current Events
NEW JERSEY TUBERCULOSIS LEAGUE
Twenty-fiftli Anniversary Meeting
The Tuberculosis League of New Jersey com-
pleted a quarter of a century of existence and of
work, at the regular Annual Meeting held at Tren-
ton, on October 16, 1931, under the presidency of
Dr. Joseph R. Morrow. Superintendent of Bergen
Pines Hospital, Ridgewood, N. J.
Congratulatory telegrams were received from
Dr. Kendall Emerson, Managing Director, Na-
tional Tuberculosis Association; Dr. William G.
Schauffler, Princeton; Dr. John F. Hagerty, Presi-
dent, Medical Society of New Jersey; and Fred J.
Hughes, President of the Board of Directors, State
Tuberculosis Sanatorium, Plainfield.
Members of the Board of Directors whose terms
expired this year were reelected for another term
of 3 years: Mrs. Charles A. Bye, Ocean County;
Dr. J. Bennett Morrison and Michael N. Chanalis,
Essex County; Dr. Stephen A. Douglass and Mrs.
G. A. Terhune, Passaic County; W. L. Kinkead
and Dr. Joseph R. Morrow, President of the
League, Bergen County; Dr. Samuel B. English,
Hunterdon; Dr. Alexander Macalister, Camden;
Charles J. Merrell, Somerset; Miss J. Palmer
Quinby, Monmouth County; Mrs. E. G. Shreve,
Atlantic County: Dr. Charles I. Silk, Middlesex;
Mrs. Luther G. Ogden, Cape May, and Eugene
Sullivan, Essex. New members elected to the
board were: Frederick D. Hopkins and Mrs. Harry
Dubois, Bergen County; Miss Elizabeth Hynes,
Monmouth; Dr. Harold S. Hatch, Morris County;
Rev. J. Marshall Wilson, Warren County; John
H. Adamson, Passaic County; Mrs. Isabelle Som-
mers, Paterson ; Edgar B. Forse, Middlesex Coun-
ty; Dr. J. Lynn Mahaffey, Camden. At its busi-
ness session the Board of Directors reelected the
present officers: Joseph R. Morrow, M.D., Presi-
dent; Martin H. Collier, M.D., Vice-President; Mrs.
E. G. Shreve, Secretary; W. L. Kinkead, Treas-
urer; Ernest D. Easton, Executive Secretary.
Dr. Emma A. Winslow, Research Director of the
State Pension Survey Commission, discussed
“County Welfare Work in Relation to Prevention
of Tuberculosis”, saying, in part:
Much progress has resulted in New Jersey from
the development of tuberculosis work under the
county plan of organization. The adequate ad-
ministration of public relief is a matter closely
related to tuberculosis prevention and control, and
it is to be hoped that New Jersey will take a for-
ward step in all counties this autumn in placing
all relief of dependency on a county rather than a
municipal basis. In order to make a county wel-
fare plan of organization possible, however, a
number of basic changes are necessary in the
“poor law”, and the adoption of such changes has
been a matter of local decision in the various
counties by action of the Legislature in requiring
a referendum vote on the “revision of the poor law”
at the election to be held on November 3. More
than $2,000,000 will be spent from county funds in
New Jersey during 1931 for the care of indigent
tuberculous persons in sanatorium^ and also nearly
$1,000,000 from state funds.
Ernest D. Easton, Executive Secretary of the
New Jersey Tuberculosis League, recounting the
progress of 25 years, said that, in the present
emergency, it is fortunate that sanitary proce-
dures are now well established and that increasing
emphasis is placed on the care of children. It is
also fortunate that the masses of the people have
knowledge of the contagiousness of tuberculosis
and knew how to safeguard their families. We
have hospitals, clinics, sanatoriums, nurses and
other machinery available to an extent unknown
25 years ago. We should cooperate with these
agencies for more effective work; and, at the same
time, we should work with unemployment and re-
lief committees so that people may have susten-
ance sufficient to maintain their resistance.
Joseph R. Moreland, Freeholder from Gloucester
County, was unable to be present, on account of
illness, and his report on the “Movement for Sana-
torium Provision for Smaller Counties” was read
by Mrs. Helen E. Schrock, Executive Secretary,
Gloucester County Health Association. Mr. More-
land reported that a State Sanatorium, similar to
Glen Gardner, had been suggested by Commissioner
William J. Ellis, of the Department of Institutions
and Agencies, for southern New Jersey counties,
at a meeting of the Freeholders of the counties in
question. This suggestion was strongly supported
by Dr. Samuel B. English, Medical Superintendent,
State Sanatorium, Glen Gardner. Mr. Moreland’s
paper was discussed by Dr. English and Miss Syd-
ney Hall. Executive Nurse, Warren County Health
Association, who told of a similar movement in
northern Jersey counties.
Dr. Harold S. Hatch, Medical Superintendent of
the Morris County Sanatorium, described inno-
vations developed there, including improvement in
the food service with a view to making meals
more attractive and tempting to the patient.
Dr. Ira De A. Reid, speaking of the “Tubercu-
lous Negro”, pointed out that while the general
death rate from tuberculosis has been declining,
that for the colored population has sharply increas-
ed during the past 2 years; figures showing the
Negro tuberculosis death rate in the state as 218
in 1928, 247 in 1929, and 264 in 1930, an increase
of 46 points (or 21%) in 2 years. This is especially
alarming when one considers that already in 1928
the Negro tuberculosis rate was 3 times as high
as the rate for white people. Dr. Reid declared
that this is not due nearly so much to racial in-
heritance as to poor economic conditions. This
is especially true today, when the Negro is the
first to be fired from a job and the last to be re-
hired. He said that this is a situation which is a
challenge to the Tuberculosis Associations of the
state, but which at the same time gives them an
opportunity for unusual results. Negro health con-
ditions being what they are, we are bound to
produce great results for every little effort that is
expended in their behalf.
Dr. Donald II. Armstrong, Third Vice-President
of the Metropolitan Life Insurance Company, said:
Many physicians rely on a child’s weight — or lack
of it — as an indication of tuberculosis. Under-
weight can no longer be considered a guide to pos-
sible tuberculosis, for in recent tests only a few
of the active cases of the disease were found
among under-weight children. In fact, more
tuberculosis was found among over-weight chil-
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
875
dren than among the under-weights. Adequate
x-ray and other facilities must be provided in
schools, and communities generally, if the disease
is to be brought under control. It also means
education of the physician in the use of this
equipment, as well as educating the public to de-
mand its provision.
Dr. J. Bennett Morrison, Secretary of the Medi-
cal Society of New Jersey, described “The Role of
the Physician in the Tuberculosis Fight’’. Physi-
cians have been leaders in tuberculosis campaigns
from their inception, and the family physician is
the proper person to teach those afflicted with
tuberculosis how to take care of themselves, and
how to protect other members of the family and
the public — through sytematic destruction of his
own infected sputum.
i Dr. Morrison urged systematic examination of
all school children, by school physicians where the
examinations have not been made by the family
doctor; the utilization of summer camps and pre-
ventoriums; the regular and repeated examination
of employees of mercantile houses and manufac-
turing plants; and extension of the campaign for
periodic health examinations of everybody.
DR. It. D. FREEMAN LAUDED AT DINNER
(Reported by Dr. E. LeRoy Wood)
Dr. Richard Dean Freeman, retiring chief of
staff of Orange Memorial Hospital, was honored
recently when more than 50 members of the senior
and junior hospital staffs gave him a dinner at
Essex County Country Club. Dr. Freeman has
reached the age limit, of 85 years, for active duty
in the hospital wards, but has no intention of re-
tiring from participation in hospital affairs or
from active practice.
The staff members met at the club in the after-
noon for a round of golf followed by the dinner,
which was featured by speeches in praise of Dr.
Freeman. Dr. Leonard H. Smith gave him, on
behalf of the staff, a golf bag and set of matched
clubs.
Dr. A. W. Bingham was toastmaster, the diners
being seated at a large table decked in green, in
tribute to Dr. Freeman’s Dublin birthplace. A
graduate of Trinity College, Dublin, he has lived
in the Oranges 40 years and has been associated
with the hospital 36 years. He served as chief of
staff 5 years, succeeding the late Dr. Mefford
Runyon.
One of the high lights of the evening was the
singing by Dr. Freeman, of “Father O’Flynn'’
with piano accompaniment by Dr. John R. Shan-
non, of New York, his friend of many years, and
formerly chief of staff of Manhattan Eye and Ear
Hospital.
Dr. Henry C. Barkhorn, of Newark, President
of the Essex County Medical Society, praised Dr.
Freeman’s spirit of cooperation and community
service. Dr. Shannon gave reminiscences of their
years of friendship and Dr. John Hammond Brad-
shaw and Dr. Thomas W. Harvey told of their as-
sociation with Dr. Freeman and with the hospital.
Dr. Harvey, who is the oldest practicing physi-
cian in the Oranges and a former hospital chief of
staff, said: “This business of age limits has its
compensations. When I first retired as chief of
staff I felt as though I had been laid away on a
high and narrow shelf, but I find the shelf has a
way of broadening with the years.'’
Dr. Freeman responded with a short speech of
appreciation. Dr. S. A. Muta, of West Orange,
was in charge of the dinner arrangements.
WOULD ELEVATE CHIROPRACTIC
(The caption above, headed a report of the
“first state-wide convention of the chiropractors
of New Jersey” as published in the Atlantic City
Press on October 12, 1931. Following a reference
to some of the business matters considered in the
convention, the Press carried what appears to be
a condensed report of the scientific program, which
we reproduce for the edification of physicians who
may be interested in one or other of the 2 prob-
lems— “Development of Posture” and “Cure for Old
Age’’’. — Ed.)
Urges Development of Posture Practice
Finds Cure for Old Age
(From Atlantic City Press, October 12, 1931.)
Dr. H. Lewis Trubenbach, of the New York
School of Chiropractic, declared that the profession
should be developed along the central idea of good
posture. Complete pressure on the spinal cord
would paralyze the patient, he pointed out. Poor
posture throws the vital organ out of position and
accounts for much illness, he declared.
Dr. Trubenbach declared that the Palmer school,
the “mother’’ of the profession, has now only one-
tenth of the students it had in 1922.
Dr. Frank M. Sindoni, of 1905 Pacific Avenue,
a local .chiropractor, told the convention that he
had succeeded in finding the cause and cure of
premature old age after months of research and
tests on individuals.
“According to my experience”, he declared, “I
have concluded that premature old age is caused
by the degeneration of the thyroid gland. By ob-
serving the activity of the thyroid gland, with the
aid of an x-ray, I have discovered pressure on the
first, fifth and sixth cervicals, and the fifth dorsal
vertebras caused indirectly, influence the thyroid
gland. After three to six months of adjustment
the flabby and drooping facial musculature and
wrinkles in the face began to < disappear J’’
Public Relations
TOBACCO
(Editorial, written by Dr. R. M. Hewitt, in Minne-
sota Medicine, April 1931, p. 359.)
On the basis of one national principle — that if
there is something people like to do there must be
some reason why they should not do it — scientific
investigators might be expected to have found
some reason unqualifiedly to condemn the use of
tobacco. On the basis of another national princi-
ple— that anything advertised with enough mil-
lions must be of virtue — it might be expected that
these same investigators would have found that
abstinence from tobacco is the hidden cause of lack
of charm or of virility. But scientific investiga-
tors are free of fixed ideas, so long as they remain
scientific.
The day may come when it will be a mark of in-
dividuality to amble a nonchalant mile for one of a
coughless consignment of cigarettes, and then se-
cretly to toast it over one’s bootleg fire; but that
day is not yet. Nor has the time come to educate
the young mother that an infusion of tobacco must
be mixed with the baby’s food for the vitamins
therein contained. Consequently, the perennial
question of the harmfulness of “nicotin, pyrilin
87G
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
and other pyrogenous compounds, carbon mon-
oxide, traces of hydrocyanic acid, phenols and al-
dehydes” continues to bloom with the violets, and
in between. And it should, for the problem needs
solution.
The effects, not of nicotin only, but of the sev-
eral chemical substances just mentioned, alone or
together, must be considered when tobacco is
smoked. Also, where it is grown, how it is cured,
whether it is moist or dry, how fast it is smoked,
how slowly, how it is wrapped, or what kind of a
pipe is used, enter into the question. Moreover,
the smoke may be inhaled or puffed, and tobacco
may not be smoked at all. Tobacco may be, at
least it used to be, chewed; whether or not circum-
stances would allow of expectoration. Doubtless
all physicians can remember certain hirsute males
who boasted that they ate theirs. As the biometri-
cian might say, several variables seem to be in-
volved.
Since these variables are not likely to be brought
into correlation by the advertising writers and the
physicians who help them with their copy, let us
see what opinions a few of the serious seekers
have evolved. In 1927, a small volume written by
Schrumpf-Pierron was published under the aus-
pices of the Committee to Study the Tobacco Prob-
lem. The bibliography contained 750 names, more
or less. Schrumpf-Pierron’s conclusions were, in
part, as follows: The study of the action of to-
bacco on the organism is still incomplete, both sci-
entifically and clinically; sound and unsound indi-
viduals react differently; immoderate doses cause
disturbances that are first functional, then organic,
and some of them are grave; disturbances have
increased infrequency as the consumption of to-
bacco, particularly of cigarettes, has increased;
the cigarette habit leads readily to abuse; further
studies are needed, particularly "statistical re-
search as to the influence of tobacco as ordinarily
used among large groups of people as compared
to the effect of abstinence among similar groups”.
That does not give much of a chance for either
the reformers or the copy writers to attack the
subject from the health angle. The investigaticn,
however, is being carried on.
W. E. Dixon, pharmacologist at Cambridge Uni-
versity, has studied the subject of the tobacco
habit. He concluded his Norman Kerr Lecture
with the statement that smoking “leads to diges-
tive circulatory disturbances”. FTe gave expression
to an impression of clinicians that many years of
continuous absorption of nicotin is responsible for
some cardiovascular conditions of middle life and
old age. However, he continued: “It may well be
that living in a civilization such as ours, under the
conditions of strain imposed by residence in cities,
the ordinary man shows in his nervous responses
variations from the normal, and on such persons
tobacco exerts a beneficial function.”
Rolleston has, in a sense, carried on the work of
Schrumpf-Pierron by collecting from literature the
views of 34 writers on the effects of tobacco. He
did not come to conclusions. Who could?
It is not easy to see how a study could be prose-
cuted more scientifically than that of Dierl, of
the University of Minnesota. He had a group of
445 smokers and one of 441 non-smokers. The
work was analyzed by biometric methods. How-
ever, as Diehl pointed out, the subjects were too
young to have suffered from degenerative changes,
if tobacco is really responsible for any such
changes. He found that the smokers had less
stable cardiovascular systems than non-smokers,
but he was careful to state that “the effect of such
a difference on health or longevity never has been
determined”. The final ratings of these groups, for
classification of physical activities, were not sig-
nificantly different.
Another relevant piece of work done in Min-
nesota is concerned with the old question of to-
bacco and thrombo-angiitis obliterans. Barker
studied the consumption of tobacco by 350 patients
between the ages of 25 and 55 years, who had
thrombo-angiitis obliterans and who had been seen
in the Mayo Clinic during the last 10 years. He
compared with this group, another that corres-
ponded with the first in every way except that the
members of it did not give evidence of peripheral
vascular disease. He found reason to believe that
tobacco is not the primary cause of thrombo-angiitis
obliterans, but that it may be a predisposing cause.
Moreover, if patients with thrombo-angiitis obli-
terans have used tobacco excessively, the condition
seems likely to run a more malignant course.
Barker expressed the belief that evidence favors
prohibition of the use of tobacco to patients with
thrombo-angiitis obliterans, but, he added, “the
data are by no means conclusive ’.
W. J. Mayo, who never has used tobacco, in
discussing Baker's report, gave the present status
of the tobacco problem as well as it can be stated:
“I have no evidence to show that a moderate use
of tobacco is harmful to the average person, but
we know that even what might be called moderate
smoking is harmful to some persons. On the whole,
smoking seems a habit which has possibilities for
harm, and has little to its credit, although many
seem to derive a good deal of comfort from it, es-
pecially those persons who have nothing to do at
the time which interests them more. Pipe smok-
ing should be the least harmful, because the pipe is
usually out, and the smoker is just as happy until
he notices the fact, which depends largely on how
much interested he is in what he is doing. The
pipe seems to be the adult pacifier which takes
the smoker back to his childhood days. Some
smokers, especially of strong cigars, have func-
tional heart trouble and it now appears that the
cigarette smoker is subject to various ills. I
doubt that much harm results to the person who
smokes a cigarette only occoasionally.”
From all that has been done thus far, it seems
that “T. M.” means both “ ’tis mince” and
“ ’tain’t mince”. The Governor of North Carolina
and the Governor of South Carolina each must
have been an excellent judge of good liquor. One
said there was iron in the whisky; the other said,
leather. When the barrel had been drained, they
found in the bottom a loose tack, iust under the
head of which was a leather gasket. Yet it is not
recorded that either governor died of hepatic cirrh-
osis. Nor is the opposite on record, for the story
is fictitious.
We need the facts about cirrhosis. We also need
them about the effect of tobacco. All encourage-
ment to those who are seeking them, and caution
to those who are inclined to jump to conclusions.
AGREE NOT TO PUBLISH DOUBTFUL .AD-
VERTISING
(The Editor of this Journal has on several oc-
casions, but particularly in his last Annual Report,
urged an active campaign against fraudulent ad-
vertising, and reprints this news item as an in-
dication that now is a favorable time to develop
such a campaign. Our readers may be interested
in learning that his cigarette editorials were not
fruitless; the Federal Trade Commission has had
some of the tobacco companies “on the spot”;
about which, more anon.)
Nov., 1931
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
877
Magazines and Papers Will Abide by Trade
Board's Action on Misleading Copy.
(From the New York Times, Sept. 13, 1931.)
The Federal Trade Commission announced to-
day, in connection with its campaign against
fraudulent advertising, that several publishers and
advertising agents have signed stipulations to
abide by the commission’s action on charges pre-
ferred against certain advertisers. In each in-
stance the agent or publisher waived his rights
to appear in proceedings as correspondent with
the advertiser. The commission did not name the
individuals or firms concerned. One New York
agency had placed for publication the advertising
copy of a corporation selling an alleged remedy
for indigestion.
The publisher of several widely circulated mag-
azines which had printed advertisements of 3 con-
cerns selling watches and Jewelry of questionable
value, as well as perfumes and an alleged cure for
the tobacco habit, agreed to stop publishing such
copy, awaiting disposition of the commission’s
cases against the advertisers.
The publisher of a motion picture magazine
agreed to stop publishing advertisements of a cure
for bashfulness.
A large Southern newspaper, which had carried
advertisements of an alleged physician offering a
competent treatment for high blood pressure,
agreed to stop publishing them pending action
against the advertiser.
The publisher of 2 magazines, printing advertise-
ments of a cream to develop various parts of the
body, agreed to abide by the commission’s action
against the advertiser.
The commission said that facts in the proceed-
ings were presented to show methods of compe-
tition condemned as unfair, to guide industry, and
to protect the public.
VACCINATION FAVORED TO PREVENT
DIPHTHERIA
League Commission Reports to International Hy-
giene Congress in Paris
(From N. Y. Times, Oct. 20, 1931.)
The commission of experts appointed by the hy-
giene committee of the League of Nations to
study the question of antidiphtheria vaccination,
which first met in London in June, 1931, has pre-
sented its findings at the International Hygiene
Congress, being held at Pasteur Institute. The re-
port is based on comparative studies and diph-
theria vaccinations following a program planned
at a meeting in Paris in July. 1929, and a study of
various documents during the last few years.
The commission approves vaccination against
diphtheria and finds it reduces mortality and acts
as a preventive. The reaction sometimes result-
ing from vaccination is found to be harmless and
should not interfere with propaganda in favor of
vaccination of all children.
The use of a mixture of toxin-antitoxin and ana-
toxine is recommended. The establishment of a
universal basis for standardization and control of
all prophylactic vaccines against diphtheria is
suggested.
The vaccine should be administered in 3 doses,
3 weeks to elapse between the first and second
doses and 2 weeks between the second and third.
Children should be vaccinated before they are of
school age or the first year they attend school.
Charitable institutions, vacation colonies, preven-
toriums and sanatoriums should demand certi-
ficates of vaccination against diphtheria from
children and from their personnel. Nurses and
the personnel of hospitals, schools and asylums
should be vaccinated. Vaccination should be the
object of active propaganda by the hygiene ad-
ministrations of all countries.
Members of the commission were Dr. Thorwald
Madsen, President of the Hygienic Commission of
the League of Nations; Dr. George W. MacCoy,
of the United States, Professor IT. H. Dale, of
London, and Professors A. Calmette and W. Colle,
of France.
SMITH URGES CLINICS OR HEALTH
INSURANCE
Ex-Governor Says Some System is Needed to
Make Treatment Available to All
(From N. Y. Times, Oct. 17, 1931.)
Some form of health insurance, or a widely es-
tablished 'system of public health clinics, whereby
health information and proper medical treatment
would be made available for every man, woman
and child, was advocated by former Governor Al-
fred E. Smith, at a conference on industrial medi-
cine and traumatic surgery, which occupied the
closing sessions of the twenty-first annual clinical
congress of the American College of Surgeons at
the Waldorf-Astoria.
Mr. Smith was one of several prominent lay-
men, representatives of industry and labor, to join
the surgeons in their campaign to give the best
medical treatment to the vast and growing num-
ber of accident victims, in industry and other-
wise. Taking as their slogan “safety afterward”,
the speakers emphasized the need of not only re-
storing the accident victim to health but to fol-
low up his case after recovery and to make sure;
that his usefulness to society is also restored to
as high a degree as science would permit.
Health Purchasable, Says Smith
“One of the first lessons I learned”, said Mr.
Smith, “was that public health was purchasable
and that its administrative application to govern-
ment, be it state or local, has wide significance.
I have seen the devastating effect of illness on a
worker’s family. We still compensate inadequately
because we have not yet succeeded in compensat-
ing for all diseases incurred in the course of oc-
cupation, which are directly traceable to the occu-
pation or industry itself. Until the law applies
generally there will continue to be cases such as
those of the workers suffering from radium poison-
ing, which occurred in New Jersey a few years
ago.
1 would like to see some system whereby health
information and proper medical treatment would
be available to every man, woman and child, re-
gardless of his position in the world, whether this
is to be done through some form of health insur-
ance or through a widely established system of
public health clinics. (Italicized by the Editor.)
The lesson in the preservation of human life
has been best illustrated in Cattaraugus County,
where an experiment was established, utilizing
every conceivable health resource in that county —
both public and private. It was so coordinated,
and made to function, that every child felt its in-
fluence before it was born, and every adult until
the last of his days.
We found at the time of the war. when we made
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Nov., 1931
careful health examinations, that 33% of the young
men suffered a' physical defect which could have
been cured had they received attention during the
early years of their lives. How much of this has
since been corrected is hard to say. Only by con-
stant effort and the constant dissemination of
knowledge can we hope to progress along these
lines.
Your organization must lead the way by giving
us the scientific facts with which we can deal. But
the state, using that word in its largest sense,
must fit those facts into effective administrative
action.'’
DOCTORS’ DILEMA
(Editorial in New York Times, Oct. 20, 1931.)
President Angell, addressing the Congress of the
American College of Surgeons, passed in review
many things that are wrong, or alleged to be
wrong, with the medical profession, but ex-
pressed particular impatience with the- “narrow-
minded” opposition to socialized medicine. Every
form of health activity developed through group
or community action is resisted by a few prac-
titioners as an .attempt to deprive them of a
living. Their attitude, said Dr. Angell, is like the
hostility of labor organizations to labor-saving
machinery.
This blunt assertion — that physicians who set
themselves up against the health activities of the
community are as foolishly engaged as the Luddite
machine-smashers of the early nineteenth century
—might be rounded out with a more cheerful mes-
sage. It has been demonstrated that labor's re-
sistance to technologic inventions is, in the long
run, against labor’s own interests. The industrial
revolution has enormously lifted the living stand-
ard of the working classes. In the same way it
might be pointed out to the doctors that increasing
Government activity in the field of public health
may redound in the long run to the material ad-
vantage of the private physician and surgeon.
In the matter of health, there are no limits to
human wants. The more of health we have, the
more we want. In concrete form this truth is
stated by Michael M. Davis, of the Julius Rosen-
wald Foundation, in his new book, “Paving Your
Sickness Bills”, published by the University of
Chicago Press. He finds from a study made by
the United States Bureau of Labor Statistics in
1918-1919 that the amount spent on illness averages
$60 a year per family. But the actual expendi-
ture ranged from $34 a year in the lowest-income
classes to $95 a year in the highest-income fami-
lies. The free services which the poor receive af- 
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